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la—DILHR SANITARY PERMIT APPLICATION COUNTY <br /> """I In accord with ILHR 83.05,Wis.Adm.Code <br /> STATESAANITA PERMIT III <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than1:1 / '&C �f <br /> 81/2x 11 inches in size. �fieck if revlsli 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 /> PROPERTY OWNER �` PROPERTY LOCATION <br /> OrClw" w(sC s '/+ u),/,S qT 5to, N, R W <br /> PROPERTY OWNER'S MAILING ADDRESS LOT# BLOCK# <br /> CITY,STATEZIP CODE PHONE NUMBER SUBDIVISION NAME OR CS NUMBER <br /> C e %bue 01110 <br /> IL TYPE OF BUILDING: (Check one) CITY NEAREST ROAD <br /> ��{{ ❑State Owned ^� VILLAGE: S��-.f- C1< <br /> ❑ Public tC�11 or 2 Fam. Dwelling-#of bedrooms AR L BER( ) <br /> 111. BUILDING USE: (If building type is public,check all that apply) ay- L oLl- C),:;) -/070 <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. ❑ New 2. X 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 /> 11Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank <br /> 12 6SeepageTrench 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 D2.ABSORP.AREA 3.ABSORP.AREA 4. LOADING RATE 5. PERC.RATE 6. SYSTEM ELEV. 7. FINAL GRADE <br /> AY <br /> REQUIRED AREA <br /> ft.) PROPOSED(sq.tt.) (Gals/day/sq.ft.) (Min./inch) ELEVATION <br /> Is q9a V ,b.,;1 7 Feet { .to Feet <br /> VII. TANK CAPACITY Site <br /> in gallons Total #Of Pretax, Fiber- Expp. <br /> INFORMATION New istin Gallons Tanka Manufacturer's Name oncret Con- Steel glass Plastic App <br /> Tanks Tanks strutted <br /> Se ticT or Holding Tank <br /> i um T Si hon Chamber <br /> VII . RESPONSIBILITY STATEMENT GE,wbO -{-pnt <br /> I,the undersigned,assume responsibility for installation of the onsite sewage system shown on the attached plans. <br /> Plumber's Name( rin : Plu bar's Signature:to mps) MP/MPRSW No.: Business Phone Number: <br /> 6M l�f g66- <br /> Plumber's Address treat,City,State,Zip Code): <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved Sanitary Permit Fee(Includes Groundwater Date Issue Issuin gent Signature(No Stamps) <br /> I'LL Surcharge Fee) <br /> Approved ❑ Owner eDetermin I3�. /_ ('�-� \ - � <br /> AdveraeD Determination �:.J `L: <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-8398(formerly Plb-67)(R.11/88) DISTRIBUTION: Original to County,One Copy To:Safety 8 Buildings Division,Owner,Plumber <br />