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�IL_HR SANITARY PERMIT APPLICATION �O�Nr ��E <br /> In accord with ILHR 83.05,Wis.Adm.Code <br /> Tr- <br /> STATESAN,ITIArRY ERMIT#�'a83r/S <br /> —Attach complete plans(to the county copy only)for the system,on paper not less than l i� � <br /> 8'%x 11 inches in size. ❑ cLk If revisioQ1to 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 TY OWNER PROPERTY LOCATION <br /> 0vc(f '/a '/a, S T ON, R E (or <br /> PROPERTY OWNER'S M I G ADDRESS LOT# �y BLOCK <br /> 373 � Ale.5. 7v <br /> ITY�ST/ATE S m • / <br /> ZIP CODE PHO/� )U - = SUBD�(I�IONN'A'ME OR CSIW NUMBER <br /> If. TYPE OF BUILDING: (Check one) C! /`LN /CIIITTYW L ��, /� fN1EEAREST ROAD <br /> ❑State Owned VILLAGE: 4QOJIa� <br /> ❑ Public 1 or 2 Fam. Dwelling,#of bedrooms EL A NUMnB ( ) U <br /> 111. BUILDING USE: (if building type is public,check all that apply) b— <br /> 1 ❑ Apt/Condo <br /> 2 El Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility <br /> 3 ❑ Campground 7 ❑ Merchandise: Sales/Repairs 11 ❑ RestauranVBar/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. 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 ❑ 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 13.ABSORP.AREA 14. LOADINGRATE 15. PERC.RATE 6. SYSTEM ELEV. 7. FINAL GRADE <br /> REQUIRED,(sq.ft.) PROPOSED( ft.) (Gals/day/sq.ft.) (Min.�/i/�ch) /j // ELEVATION <br /> ��� 7 1 , 7 T `75T Feet (Y-d Feet <br /> VII. TANK CAPACITY Site <br /> in allona Total #of Prefab. Fiber- Exper. <br /> INFORMATION New Istin Gallons Tanks Manufacturer's Name oncret Con- Steel glass Plastic Apo. <br /> Tanks Tanks strutted <br /> Septic Tank or Holdin Tank <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:IN mps) MPIMPRSW No.: Business Phone Number: <br /> Plumber's Add Sa(Street,City,State,Z p Code): <br /> P.O. ,� /Cz3 lac el�s{�r, isc/I �� 3 <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> Disapproved I Sanory Permit Fee(Includes Groundwater Date IssuedIssu' gent Sipe re(No Stamps) <br /> Owner Given Initial <br /> l(y� I��' Surcharge Fee) <br /> Approved ❑ `�7F,YI <br /> Advers Determination <br /> X. CONDITIONS OF APPROVAUREASONS FOR DISAPPROVAL: <br /> SBD-6398(formerly Plb-67)(R.11/38) DISTRIBUTION: Original to County,One Copy To:Safety&Buildings Division,Owner,Plumber <br />