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�ILHR SANITARY PERMIT APPLICATION COUNTY <br /> In accord with ILHR 83.05,Wis.Adm.Code 15 q <br /> �f Nn e4'7— <br /> STATEaSANITARERMIT#�S// i II <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than C//Lx j� <br /> 8'%x 11 inches in size. ❑ Check if rev on 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 /> �Z I ctv N 1.(I%S '/4, S T Yo, N, R f{or) <br /> PROPERTY OWNER'S MAILING ADDRESS LOT# BLOCK# <br /> 133 Men^foe N. 0, 11 1 <br /> CYlTAiTE PHONE NUMBER SUBDIVISION NAME OR M NUMBER <br /> DE W ` UO Q Pr V111a <br /> II. TYPE OF BUILDING: (Check one) L1 State Owned VILLAGE NEAR ST OAD <br /> v t eP <br /> ❑ Public 1 or 2 Fam. Dwelling-#of bedrooms FOARWATARNUM (� <br /> III. BUILDING USE: (if building type is public,check all that apply) -pLb —woo — <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 8 if applicable) <br /> A) 1. N 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 /> 11Seepage Bed 21 ElMound 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 DAY 12.ABSOIRP.AREA 13.ABSORP.AREA 14. LOADINGRATE 15. PERC.RATE 6. SYSTEM ELEV. 7. FINAL GRADE <br /> REQUIRED(sq.ft.) PROPOSED(sq.ft.) I (Gals/day/sq.ft.) I (Min./inch) pp�eei ELEVATION <br /> 41s,- 6 i —aZ' D_ . O Feet ?J Feet <br /> VII. TANK CAPACITY Site <br /> in allons Total #of Prefab. Fiber- Exper. <br /> INFORMATION New xistin Gallons Tanks Manufacturer's Name oncret Con- Steel glass Plastic App <br /> Tanks Tanks strutted <br /> SioticTan r Holdin Tank /e3,� <br /> Lift Pum Tank/Siphon 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): Plu bar'sgnaturStamps) MP/MPRSW No.: Business Phone Number: <br /> Nis (, W-P S7o'�L7/ S- -�� � <br /> Plumber's A.dSd=aa( tregt,Ciry,State,Zip Code):WwS �r <br /> IX C60GUE/NTY/DEPAAR ENTL7USSE ONLY f -J <br /> Disapproved Sanitary Permit Fee(Includes0 Groundwater ate IssuedIssuing gent Signature(No Stamps) <br /> Approved ❑ Owner Given Initial j/�� oU 't"_ <br /> Adverse Determination /l/ <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 />