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7DILHR SANITARY PERMIT APPLICATION COUNTY <br /> In accord with ILHR 83.06,Wis.Adm.Code <br /> STATE SANITAR RMIT#�'/_/�11 <br /> —Attach complete plans(tot a county copy only)for the system,on paper not less than /'77 — I�`� I <br /> 8'%x 11 inches in size. ❑ Chleck if revI o previous application <br /> —See reverse side for Instru Alone for completing this application. STATE PLAN I.D.NUMBER <br /> I. APPLICANT INFORMATI N-PLEASE PRINT ALL INFORMATION. <br /> PROPE TY OWNER PROP RTY LOCATION <br /> ( '/a Ys,S T N, R E ( r)W <br /> PRO R WNER'S MtLINGA DRESS L T# BLOCK III <br /> CITY,STATE IP ODEPHONE NUMBER SUBDIYJSION NAME OR CSM NUMBER a.r (<Z <br /> C V! • '83 <br /> Lj fa <br /> II. TYPE OF BUILDING: (Ch ick one State Owned <br /> CITY NEAREST ROAD <br /> VILLAGE: f `�� <br /> m <br /> ❑ Public X1 or 2 a .Dwelling-#of bedrooms G <br /> III. BUILDING USE: (If buildi ig 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 ❑ Restau ranttBar/Din ing <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: (Chef k only one in line A. Check line B if applicable) <br /> A) 1.kNew 2. E1Replacement 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: (Chc ck only one) <br /> Non-Pressurized Distribu ion Pressurized Distribution Experimental Other <br /> 11 <br /> Seepage Bed 21 ❑ 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 ElSystem-In <br /> -Fili <br /> VI. ABSORPTION SYSTEM NFORMATION: <br /> 1.GALLONS PER2.AE SORP.AREA 13.ABSORP.AREA 14. LOADING RATE 15. PERC.RATE 6. SYSTEM ELEV. 7. FINAL GRADE <br /> _,..[,,) DAY REQ IRED(sq.ft.) PROPOSED(sq.ft.) (Gals/day/sq.ft.) (Min./inch) ELEVATION <br /> ' Imo52 t. r S.1 Feet 1 C17.I Feet <br /> VII. TANK CAPACITY Site <br /> in gallons Total #of Prefab. Fiber- Exper. <br /> INFORMATION New istin Gallons Tanks Manufacturer's Name oncret Con- Steel glass Plastic App <br /> -ranks I Tanks structed <br /> Septic Tank or Holdin Tank �' <br /> Lift Pump Tank/Siphon Chamber <br /> Vlll. RESPONSIBILITY STATEMENT <br /> I,the undersigned,assume re iponsibility for installation of the onsite sewage system shown on the attached plans. <br /> Plumber's Name(Print): Plumber's Signature:(No pa) MP/MPRSW No.: Business Phone Number: <br /> fit-14fiRD APA-lf& 3`fZb S 6- IS <br /> PI tuber's Address treeL City, te,2ip Code. 7 �) <br /> 9A9 5 <br /> IX. COUNTYY//DEPARTMEN U E ONNLLY C <br /> Disapproved Sanitary Permit Fee(includes Groundwater DateIssued( Isau g Ag nt Signatur Stamps) <br /> Approved ❑ Owner Given Initial Surcharge Fee) - / 1 <br /> Adverse Del rmin tion I Z` <br /> X. CONDITIONS OF APPR VAUREASONS FOR DISAPPROVAL: <br /> SBD-6398(formerly Plb-67)(R.11/ ) DISTRIBUTION: Original to County,One Copy To:Safety a Buildings Division,Owner,Plumber <br />