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(� SANITARY PERMIT APPLICATION <br /> 5ILHR In accord with ILHR 83.05,Wis.Adm.Code coCOUNTYLJ <br /> r <br /> STATES NITARY RMIT#'n/s3 <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than <br /> 8'/z x 11 inches in size. ❑ c ra previous application <br /> -See reverse side for Instructions for completing this application. STATE PLAN I.D. UMBER <br /> I. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION. <br /> PROPERTY OWNER JPORCP <br /> TY LOCATION <br /> rt""/a '/a ''/a, S `� T3 , N, R E (Or <br /> PROPERTY OWNER'S MAILING ADDRESS T# BLOCK# <br /> Y4 �CITY,STATE ZIPCODE PHONE NU BERBDIVISION NAME OR CSM NUMBER <br /> UO <br /> II. TYPE OF BUILDING: (Check one) CITY NEAR ST ROAD <br /> ❑ State OwnedVILLAGE m er-WOA) kco 6e,r-r❑ Public 1Z1 or 2 Fam.Dwelling-#of bedroomAXNuIII. BUILDINGUSE: (If building type is public,check all that ap ) 8 —33��- <br /> 1 ❑ ApVCondo <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. I(�7��New 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5.ElRepair 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 /> 11Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank <br /> 12 RSeepage 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 2.ABSORP.AREA 3.ABSORP.AREA 4. LOADING RATE 5. PERC.RATE 6. SYSTEM ELEV. 7. FINAL GRADE <br /> REQUIRED(sq.ft.) PROPOSED(sq.ft.) (Gals/day/sq.ft.) (Min./inch) ELEVATION <br /> '30 00 Y 6 r 6 96- 6 Feet Feet <br /> VII. TANK CAPACITY Site <br /> in allons Total #of Prefab. Fiber- Exper. <br /> INFORMATION New istin Gallons Tanks Manufacturer's Name oncret Con- Steel glass Plastic App <br /> Tanks Tanks strutted <br /> Septic Tank or Holdinct Tank - -` / <br /> Litt Pump 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): PI bar's Signature:(N tamps) MP MMPF SW No.: Business Phone Number: <br /> J R 4,1I Son/ (.Awe ) nw' -7/S 3ULl Sk1 <br /> Plumber's Address(Street,City,State,Zip Code): <br /> S O LAt e v e ui S �z e. i t2J/ S`Y k 7i <br /> I OUNTY/D PAR ENT USE ONLY <br /> ❑ Disapproved I Sanitary Permit Fee(Includes Groundwater Date Issued IssuingApproved F-1 Owner Given Initial ant Signature(No Stamps) <br /> /0J O Surcharge Fee) b^��� � <br /> 0 <br /> Ap <br /> Adverse Determination <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(formerly Plb-67)P.11/88) DISTRIBUTION: Original to County,One Copy To:Safety&Buildings Division,Owner,Plumber <br />