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SANITARY PERMIT APPLICATION <br /> LHR In accord with ILHR 83.05,Wis.Adm. Code couNTv�ur <br /> STATE/SANITARq_Yy\PERMIT#),Ag3,-j7 <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than ❑ ChI47 <br /> 8'%x 11 inches in size. eck 9 revisl6n to previous application <br /> -See reverse side for Instructions for completing this application. STATE PLAN I.D.NUMBER <br /> I. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION. <br /> PROP RTY WNER PROP LOCATION //� <br /> i(/!�'/a, S /� T mac/N, R / E(Orro <br /> PROPERTY OWNER'S M (LING 0 DRE LOT# BLOCK# <br /> CI STA ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER <br /> It. TYPE OF BUILDING: (Check one) F-1State Owned VILTML AGE NE EST/R)O <br /> OWN OF� <br /> ❑ PublicPd 1 or 2 Fam. Dwelling-#of bedroomsFARICEL TAX N <br /> Ill. BUILDING USE: (If building type is public,check all that apply) �3 _f L/ 1 4- /9 -5/`�'f� <br /> 1 ElApt/Condo 10 �l 1 V <br /> 2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility <br /> 3 ❑ Campground 7 ❑ Merchandise: Sales/Repairs 11 ❑ Restaurant/Bar/Dining <br /> 4 ❑ Church/School 8 ❑ Mobile Home Park 12 ❑ Service Station/Car Wash <br /> 5 ❑ Hotel/Motel 9 ❑ Office/Factory 13 ❑ Other: Specify <br /> IV. TYPE OF PERMIT: (Check only one in line A. Check line B if applicable) <br /> A) 1. New 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5.❑ Repair of an <br /> System System Tank Only Existing System Existing System <br /> B) ❑ A Sanitary Permit was previously issued. Permit# — Date Issued <br /> V. TYPE OF SYSTEM: (Check only one) <br /> Non-Pressurized Distribution Pressurized Distribution Experimental Other <br /> 11 Seepage Bed 21 El 30 ❑ Specify Type 41 F-1Holding Tank <br /> 12 ❑ Seepage Trench 22 ❑ In-Ground 42 ❑ Pit Privy <br /> 13 ❑ Seepage Pit Pressure 43 ❑ Vault Privy <br /> 14 ❑ System-In-Fill <br /> VI. ABSORPTION SYSTEM INFORMATION: <br /> 1.GALLONS PE7 2.ABSORP.AREA 3.ABSORP.AREA 4. LOADING RATE 5. PERC.RATE 6. SYSTEM ELEV. 7. FINAL GRADE <br /> REOUIR {sq.ft.) PROPO D aq.ft.) (Gals/day/sq.ft.) (Min./in h) ENATION <br /> O •� Feet Feet <br /> VII. TANK CAPACITY Site <br /> in allons I Total #of NCon- Steel Prefab. Fiber- Exper. <br /> INFORMATION New istin Gallons Tanks Manufacturer's Name Concreteglass Plastic App <br /> Tanks far strutted <br /> Septic Tank or HoldinTank <br /> Lift Pum Tank/Siphon Chamber <br /> VIII. RESPONSIBILITY STATEMENT <br /> I,the undersigned,assume responsibility for installation of the onsite sewage system shown on the attached plans. <br /> Plumber's Name(Print): Plumber's Signature: Stamps) MP/MPRSW No.: Business Phone Number: <br /> 1� It7/S - <br /> Plurper's Add am(Street,City,State,Zip Code: <br /> ,, COUNTYIDEPARTMENT USE ONLY <br /> Disapproved Sanitary Permit Fee(includes Groundwater I Date issued Iss g gent Sign a(No Stamps) <br /> Approved ❑ Owner Given Initial surcharge Fee) <br /> Adverse Determination 105. 1 �1- <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6399(formerly Plb-67)(R.11/88) DISTRIBUTION: Original to County,One Copy To:Safety 8 Buildings Division,Owner,Plumber <br />