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SANITARY PERMIT APPLICATION COUNTY <br /> la_ M00010011 DILHR In accord with ILHR 83.05,Wis.Adm.Code Q, ,r <br /> STATE SANITARY PERMIT#nfv­ <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than ® 0q)(0q <br /> 8%x 11 inches in size. check If revisio 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 /> PRO ERTYOWN PROPERTY LOCA ION ,,//,n, <br /> O� C '/e /a, S 7 T VO, N, R E (orb <br /> PROPERTY ER.S MAILING ADDRESS LOT# / BLOCK# <br /> �ZVCITY,STATE ZIPCODE PHONE NUMBER SUBDIVISION NAME ORCS NUMBER <br /> / r3) <br /> It. TYPE OF BUILDING: (Check one) ❑State Owned CITY ILLAGE ry (lam/ ' y�/T`/� N REST ROAD <br /> , of/- GYr�s Or�cie <br /> ❑ Public 1 or 2 Fam. Dwelling-#of bedrooms R L Ax u ER(S) <br /> III. BUILDING USE: (If building type is public,check all that apply) �Sv- Y'- �- 03 0,30 <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. I7�N{New 2. El Replacement 3. El Replacement of 4. LJ Reconnection of 5.El Repair of an <br /> System System Tank Only Existing System Existing System <br /> B) ® A Sanitary Permit was previously issued. Permit# !,33qDate Issued S-I -fig <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 7 2.ABSORP.AREA 3.ABSORP.AREA 4. LOADING RATE 5. PERC.RATE 6. SYSTEM ELEV. 7. FINAL GRADE <br /> REOUIR D(sq.ft.) PROPOSED(sq.ft.) (Gals/day/sq.ft.) (Min./inch) LEVATION <br /> 3fO /0 �D �� a 915.9 Feet I- 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 Holdin Tank '- ' <br /> Lift Pum Tank/Si hon 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:(No Stamps) MP/MPRSW No.: Business Phone Number: <br /> Q(/e IhD�M Z--/ �, 1 It f�G <br /> Plumber's Address Street,City,Stale,Zip Code): <br /> e. S. o. &X 2f u/en/6- U/j- .-7/X,& <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved Sanitary Permit Fee(Includes Groundwater Date IssuedI n Agent Signal No Stamps) <br /> Approved ❑ Owner Given Initial d1 I CC a ,surcharge Fee) q_ 7- <br /> Vq <br /> Adverse Determination SLI -.J (�� zezz <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&Buildings Division,Owner,Plumber <br />