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UILHR SANITARY PERMIT APPLICATION COUNTY <br /> s In accord with ILHR 83.05,Wis.Adm.Code <br /> mmoms !')dri^ e <br /> —Attach complete plans(to the county copy only)for the system,on paper not less than ❑STATEANITARY PERMIT# <br /> (—n go) 9 <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 /> PROPERTY OWNER PROPERTY LOCATION <br /> aN .� '/a5/Ll '/a, S 3 Tjt/ , N, R / // E(or <br /> PROPERTY OWNER'S MAILING ADDRESS y (p-r BLOCK# <br /> U l c r1 1 'e C1� AIA <br /> CIN,STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER <br /> 0 0 e Jr O/ A <br /> II. TYPE OF BUILDING: (Check one <br /> CITY <br /> NEAREST ROAD <br /> ) ❑State Owned VILLAGE: / <br /> �MgRgl / / <br /> ❑ Public 1 ar 2 Fam.Dwelling vs <br /> of bedrooms A <br /> III. BUILDING USE: (If building type is public,check all that apply) (� — /O3— S —�(`��-'� <br /> 1 EJApt/Condo ^"�{ �`JJ <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,N Seepage Bed 21 El Mound 30 El SpecifyType 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 14. LOADING RATE 15. PERC.RATE 16. SYSTEM ELEV. 7. FINAL GRADE <br /> / REQUIRED(sq.ff.) PROPOSED(sq.ft.) (Gals/day/sq.ft.) (Min./inch) U ELEVATION <br /> (O O O d S'- A 9 /r a Feet 9 G• 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 <br /> Tanks Tanks structed App. <br /> Se tic Tank orHoldin Tank / 50 0 d5o <br /> Lift Pump Tank/Siphon Chamber, )f d 1 G 71, <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'ssignature:(No S pa) MP/MPRSW No.: Business Phone Number: <br /> Plumber's Ad ess(Street,City,State,Zip Cod <br /> /51//- / o n.e- <br /> I COUNTY/DEPARTMENT USE ONLY <br /> Disapproved Sanitary Permit Fee(Includes Groundwater Date Issue Issu g gent Signat oStamps) <br /> Approved ❑ Owner Given Initial �} IC/1 , Surcharge Feel <br /> Adv Det rmin n tel# ��JJIVJ�(�) <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(formerly Plb87)(R.11/88) DISTRIBUTION: Original to County,One Copy To:Safety 8 Buildings Division,Owner,Plumber <br />