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SANITARY PERMIT APPLICATION <br /> 70ILHFI In accord with ILHR 83.05,Wis.Adm. Code COUNTYb. .rn ^Lam_ <br /> STATE SANITARY PERMIT# �5� 3 <br /> —Attach complete plans(to the county copy only)for the system,on paper not less than // <br /> 8%x 11 inches in size. ❑ Check If revisio previous application <br /> -See reverse side for instructions for Completing this application. STATE PLAN I.D.NUMBER <br /> 1. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION. <br /> PROPERTY OWNER PROPERTY LOCATION <br /> JE 0 (. L 't/aSfC Ya, S 3(o T N, R E(or W <br /> PROPERTY OWNER'S MAILING ADDRESS LOT# BLOCK# <br /> 3LG0 AkTE RC I <br /> �� JATE n M� Z�C( ) O PHOIN'E NU BER SUBDIVISION NAME OR MNUMIBER�� <br /> II. TYPE OF BUILDING: (Check one) Vl 11WI CITY Ld NEAREST J <br /> ❑ State Owned 0 VILLAGE: SWI 55 1 L1 L)j LAMt <br /> ❑ Public X 1 or 2 Fam. Dwelling-#of bedrooms 2n NO NUMIShIl(b) f <br /> III. BUILDING USE: (If building type is public,check all that apply) <br /> 1 ❑ Apt/Condo <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.X 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 Mound 30 ❑ Specify Type 41 ❑ Holding 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 PER DAY 12.ABSORP.AREA 3.ABSORP.AREA 4. LOADING RATE 15. PERC.RATE 6. SYSTEM ELEV. 7. FINAL GRADE <br /> REO IRED(sq.ft.) PROPOSED(sq.ft.) (Gals/day/sq.ft.) (Min./inch) ELEVATION <br /> 3 oo k 0 93 -, Feet �. Feet <br /> VII. TANK CAPACITY Site <br /> in allons Total #ofPrefab. Fiber- Exper. <br /> INFORMATION New istin Gallons Tanks Manufacturer's Name oncreta Con- Steel glass Plastic App <br /> Tanks I Tanks structed <br /> Septic Tank or Holdino Tank joycli <br /> Lift Pump Tank/Siphon Chamber <br /> Vlll. 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:(No Stamps) MP/MPRSW No.: Business Phone Number: <br /> N ePk/ 03,+2 + - <br /> tumDer's Address(Street,City,State,Zip Coda): <br /> 7 w 35 rB5tE2 ( 5189 3 <br /> I COUNTYIDEPA TMENT USE ONLY <br /> Disapproved Sanitary Permit Fee(Includes Groundwater Date Issue Issu g ant Signal o Stamps) <br /> Approved ❑ Owner Given Initialc� Surcharge Fee) <br /> Adverse Determination _—FY /0S' 0D <br /> X. ONDIT,DNS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-8398(formerly Plb-67)(R.11/88) DISTRIBUTION: Original to County,One Copy To:Safety&Buildings Division,Owner,Plumber <br />