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7DILHR SANITARY PERMIT APPLICATION COUNTYt <br /> In accord with ILHR 83.05,Wis.Adm.Code IL^1SI�11 � <br /> f. <br /> STATE SANITARY ERMIT# J?�t'C� <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than ❑ Cjb3�� <br /> 8%x 11 inches in size. check if revision 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 /> Vd <br /> PROP OWNER PROPERTY LOCATION ''zz <br /> 667,1V ''/a, S L� TT <br /> N, R E (oW <br /> PR ERTY OWNER'S MAILINGAD ESS LOT# LOCK# <br /> 7— 0-t1 S - 5r1 (Po <br /> ITY,STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER <br /> N o4 n v v <br /> El CITY NEAREST ROAD <br /> It. TYPE OF BUILDING: (Check one p <br /> ❑State Owned �7 VILLAGE: Lv1� K 19 <br /> ❑ Public t61 or 2 Fam. Dwelling-#of bedrooms _ A Ax N ER( Tl <br /> Ill. BUILDING USE: (If building type is public,check all that apply) /`�' "Oa- <br /> OG- 900 <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) 1.0 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 I Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 El Tank <br /> 12 4 Seepage Trench 22 ❑ In-Ground 42 El 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 3.ABSORP.AREA 14. LOADING RATE 5. PERO.RATE 6. SYSTEM ELEV. 7. FINAL GRADE <br /> RE IRED(sq.ft.) PR Q ED(sq.ft.) (Gals//day/sq.ft.) (Mi ./inch) r ELEVATION <br /> 31)0 b�p t0 5 Feet W_1Feet <br /> VII. TANK CAPACITY Site <br /> in allons Total #of Prefab. Fiber- Exper. <br /> INFORMATION New istin Gallons Tanks Manufacturer's Name Concret Con- Steel glass Plastic App <br /> strutted <br /> Tanks Tanks <br /> Septic Tank or Holding Tank <br /> Lift 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 Stamps) MP/MPRSW No.: Business Phone Number: <br /> 3L �IS 8 1S <br /> Plumber's Address(Street,City,State,Zip Co <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved Sanitary Permit Fee(includes Groundwater ae ssue Issuing AI Signature(No Stamps) <br /> -,h Surcharge Fee) <br /> Approved ❑ owner Given Initial ;yK I!\� rg� _ , -C <br /> Adverse Det rmination �-H' 1 V CO <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 />