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-7DILHR SANITARY PERMIT APPLICATION COUNTY <br /> In accord with ILHR 83.05,Wis.Adm.Code ur <br /> =momsSTATE SANITARY P RMIT# <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than (/4365t <br /> ���(Gyln <br /> 8%x 11 inches in size. ❑ Check if revisio o 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 OWNER1� PROPERTY LOCATION <br /> -T-0N d 11SnJrr TWY41)W 1/4,S T U, N, R /SE (or W <br /> PROPERTY OWNEWIVAILING ADDRESS LOT# BLOCK# <br /> 7 Y ,— 6, S 0- I uk <br /> CITYTATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER <br /> �!t 4Ali <br /> s h'� Wor..r!Cr ,u e s 7 /add: . VV <br /> II. TYPE OF BUILDING: (Check one) CITY � NEAR ST ROq/D <br /> lf��, ❑ State Owned VILLAGE J r1C/fro j 66a AJ ) t /U�'� r 4N' <br /> ❑ Public L�r1 or 2 Fam. Dwelling-#of bedrooms L TAX NU ER( ) <br /> III. BUILDING USE: (If building type is public,check all that apply) <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. TYIIPE OF PERMIT: (Check only one in line A. Check line B if applicable) <br /> PE� <br /> A) 1. Lp 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 El 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 2.ABSORP.AREA 13.ABSORP.AREA 14. LOADING RATE 5. PERC.RATE 16. SYSTEM ELEV. 17. FINAL GRADE <br /> REQUIRED(sq.ft.) PROPOSED(sq.ft.) (Gals/day/sq.ft.) (Min./inch) // pELEVATION <br /> 3 @ C) �� ILG / Feet / <.7 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 /> Se tic Tank or Holdin Tank <br /> Lift Pum 7anWSi 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 /> /1 o rtc.A- 1' <br /> Plumber's Ad r ss(Street,city,State,Zip Code):�p <br /> LJ,"— `fi <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> Disapproved Sanitary Permit Fee (Includes Groundwater Datessue Issuing Agent Signature(No Stamps) <br /> Approved ❑ Owner Given Initial Surcharge Fee) <br /> .r# 1O�` cc <br /> Adverse Dmin tI n �lY I <br /> X. CONDITIONS OF APPROVALIREASONS FOR DISAPPROVAL: <br /> SBD-6398(formerly Plb-67)(R.11/89) DISTRIBUTION: Original to County,One Copy To:Safety&Buildings Division,Owner,Plumber <br />