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7DILHR SANITARY PERMIT APPLICATION <br /> COUNTY <br /> In accord with ILHR 83.05,Wis.Adm.Code <br /> STATE SANITAf ERMIT#aC)�� <br /> O' � <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than D <br /> 8'%x 11 inches in size. ❑ cne r ,n to previous application <br /> -See reverse side for Instructions for Completing this application. STATE PLAN I.D.NUMBER <br /> 1. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION. <br /> PROPERTY OWNER PROPERTY LOCATION <br /> 6We C '/e ''/e,S70 TN, R E (o W <br /> PROPERTY OWNER'S MAILING ADDRESS LOT# BLOCK# <br /> 2002MKE c RD , <br /> CITY,STATE ZIP CODE PHONE NUMBER SUBDIVIS ON NAME ORER <br /> iCS NUM� ol/JLaK�� <br /> II. TYPE OF BUILDING: (Check one) 13 CITY NEAREST ROAD <br /> ❑ State Owned ; D - <br /> ❑ Public �1 or 2 Fam.Dwelling-#of bedrooms7== L Ax Nu <br /> 111. BUILDING USE: (If building type is public,check all that apply) �s-ba arc, <br /> 1 ❑ Apt/Condo <br /> 2 El Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility <br /> 3 E] Campground 7 El 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 /> 11 Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ElHolding 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 2SORP.AREA 13.ABSORP.AREA 14. LOADING RATE 15. PERC.RATE 16. SYSTEM ELEV. 7. FINAL GRADE <br /> REQUIRED(sq.ft.) PROPOSED(sq.ft.) (Gals/day/sq.ft.) (Mi ./inch) Q ELEVATION <br /> 3®0 Z I S -3> Feet Feet <br /> CAPACITY <br /> VII. TANK Site <br /> in gallons Total #of NPrefab. Fiber- Exp <br /> INFORMATION p. <br /> New istin Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App <br /> Tanks Tanks strutted <br /> Septic Tank or Holding Tank i F1 <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): Plumber's Signature:(No Sta ) MP/MPRSW No.: Business Phone Number: <br /> -ZoAAZjD 4-10? R11.113 2� IS 4U6- IS <br /> Plumber's Address(Street,City,State,Zip Code): <br /> 2-T7160 35 3 <br /> IX. COUNTY/DEP RTMENT USE ONLY <br /> 0 Disapproved Sanitary Permit Fee(Includes Groundwaterae Issued Isatin A nt Si atur Stamps) <br /> Approved ❑ Owner Given Initial �' Surcharge Feel u1 <br /> Adverse Determination -4 I3�n ` c '7—R//_q3 <br /> X. C NDITIONS OF APPROVALIREASONS FOR DISAPPROVAL: <br /> SBD-6398(formerly Plb-67)(R.11/88) DISTRIBUTION: Original to County,One Copy To:Safety&Buildings Division,Owner,Plumber <br />