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SANITARY PERMIT APPLICATION <br /> TDILHR In accord with ILHR 83.05,Wis.Adm.Code couNTY `\ ^ <br /> _ ,3 <br /> STATE SAS If�Y PERMIT# <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than (� l,-�\ o\t <br /> 8'%x 11 inches in size. Check It revision to previous application <br /> -See reverse side for instructions for completing this application. I� n STATE PLAN I.D.NUMBER <br /> 1. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION. 1 <br /> PROPERTY OWNE PROPERTY LOCATION <br /> o i1 ) Lc%2- 5 .5,5-% /V C'/a, S oZ P T yZ N, R h< E (or) <br /> PROPERTYOWNER'S MAILING ADDRESS LOT# BLOCK# <br /> ,? a 5- — — <br /> CITY,STATE I ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER <br /> yn36u� w� </5'3d — <br /> 11. TYPE OrF BCheck one) CITY / NEAREST ROAD <br /> ( ) State Owned ❑ VILLAGE © / <v <br /> f�I <br /> ❑ Public 91 or 2 Fam. Dwelling-#of bedrooms A L AXNUM <br /> Ill. BUILDING USE: (If building type is public,check all that apply) C- <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. ® 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 El HoldingTank <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 91 2.ABSORP.AREA 3.ABSORP.AREA 4. LOADING RATE 5. PERC.RATE 6. SYSTEM ELEV. 7. FINAL GRADE <br /> REQUIRED(aq.ft.) PROPOSED(sq.ft.) (Gals/day/sq.ft.) (Min./inch) / ELEVATION <br /> 112 Feet` �� Feet IpFeet <br /> VII. TANK CAPACITY Site <br /> in gallops. Total #of Prefab. Fiber- Exper. <br /> INFORMATION New istn Gallons Tanks Manufacturer's Name oncret Con- Steel glass Plastic App <br /> Tanks Tanks strutted <br /> Se tic Tank or Holding Tank 000 Ffo <br /> Lift Pum 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): Pluum7be,,r's Signature:(No temps) .li1r/MPRSW/No.: Business Phone Number: ry <br /> ,cZ <br /> Plumb is Address(Street,City,State,Zip Code): <br /> 7 o .B a.�- .5-/X -5/ <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> Disapproved Sanitary Permit Fee(Includes Groundwater Date ssue Issuing g nt Si natu e o raps) <br /> X< <br /> � harge Fee) <br /> Approved ❑ Owner Given Initial <br /> Adverse termin i <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(formerly Plb-67)(R.11/88) DISTRIBUTION: Original to County,One Copy To:Safety a Buildings Division,Owner,Plumber <br />