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7DILHR SANITARY PERMIT APPLICATION P�ViSlOnl <br /> Cou TY <br /> In accord with ILHR 83.05,Wis.Adm. Code <br /> = T <br /> STATE SANITARY PERMIT#' <br /> —Attach complete plans(to the county copy only)for the system,on paper not less than `7 D <br /> 8'%x 11 inches in size. �t 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 /> PROP TV OWNER PROPERTY LOCATION <br /> L S T39N, R E (or <br /> PROP RTYOWNER'S MAILING ADDRESS LOT# BLOCK# <br /> 5r COO& 11T, LaT lt_ 94 <br /> CI <br /> TATE ZIP CODE PH NE NUMBER SUBDIVISION NAME OR CSM NUMBER <br /> N- s o /a) 7 A/A <br /> II. TYPE OF B LDING: (Check one) ❑State Owned VILLAGE NEAREST ROAD <br /> Qg OF' <br /> FUON w <br /> ❑ Public Xtor2Fam. Dwelling-#ofbedrooms:2__ FkAHUP <br /> AX UMB ( ) <br /> Ill. BUILDING USE: (If building type is public,check all that apply) ` / .— 3 �2J <br /> 1 Apt/Condo ✓ t U J � 7 J <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 /> 11Seepage Bed 21 ElMound 30 ❑ SpecifyType 41 EJHolding Tank <br /> 12 9 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 72.ABSORP.AREA 3.ABSORP.AREA 4. LOADING RATE 5. PERC.RATE 6. SYSTEM ELEV. 7. FINALGRADEQQREQUIRED(sq.ft.) PROPOSED(sq.ft.) (Gals/day/sq.tt.) (Min./inch) �i �/ ELEVATION <br /> lt✓ A� / ' � Feet r (O Feet <br /> CAPACITY <br /> VII. TANK Site <br /> INFORMATION e a Xlstlons Total #of Prefab. Fiber- App. <br /> New Iatln Gallons Tanks Manufacturer's Name oncret Con- Steel glass Plastic App <br /> Tanks Tanks (nJ at <br /> Septic Tank or Holdina 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): �I ' l PI is etu e4No ps) P PRSW No.: Business Phone Number: <br /> umber's Addres9s(Stre t,City,State,Zip f, <br /> 7 <br /> COUNTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved San tary Permit Fee(Includes Groundwater Date IssuedIss ' Agent Signat (No Stamps) <br /> Approved ❑ Owner Given Initial surcharge Fee) �/'' <br /> Determination /0.5'00 'D-6_ff <br /> Adverse <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 8 Buildings Division,Owner,Plumber <br />