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SANITARY PERMIT APPLICATION <br /> DILHR In accord with ILHR 83.05,Wis.Adm.Code COUNTY <br /> STATE SANITARYPEMIT#j'��/i,7/� <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than ❑ SAN�13,l i <br /> Ch k <br /> 6'b x 11 inches In size. If revislon 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 RTY OWNER PROPERTY LOCATION <br /> 1/.�{/!(!/a, S _5T , N, R /LE (or <br /> PROPERTY WNER'S MAI ING ADDRESS LOT# BLOCK# <br /> CITY STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER <br /> II. TYPE OF BUILDING: (Check one) CITY NEA EST RO D <br /> State Owned 9 VILLAGE I Ylo / ?;;D <br /> O_,/ /I <br /> ❑ Public 1 or 2 Fam. Dwelling-#of bedrooms¢S_ Aff U/M/BE tq Jmi , �/ T/ <br /> Ill. BUILDING USE: (If building type is public,check all that apply) /D--3303-03- 60D <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. New 2. ❑ Replacement 3. ElReplacement of 4. ❑ Reconnection of 5.ElRepair 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 .ISI Mound 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 2.ABSORP.AREA 3.ABSORP.AREA 4. LOADING RATE 5. PERI.RATE 6. SYSTEM ELEV. 7. FINAL GRADE <br /> 3� <br /> REQUIRED^(sq.ft.) PROPOSED(sq.ft.) (Gals/day q.ft.) (Min./inch) ELEVATION <br /> _o 90 9 Feet Feet <br /> VII. TANK CAPACITY Site <br /> in allons Total #of Prefab. Fiber- Exper. <br /> INFORMATION New istin Gallons Tanks Manufacturer's Name ccncret Con- Steel glass Plastic App <br /> Tanks Tanks strutted <br /> Se tic Tankor Holdin Tank 57_) i <br /> Lift Pump Tank/Siphon Chamber W IJ`I� I Ll I LJ <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: Stamps) MP/MPRSW No.: Business Phone Number: <br /> lr�Qde ,�u /x✓m � / �7/5 Slab- �� <br /> Plumber's Address(Street,City,State,Zip Code): <br /> Trac e.-5. O. &Y /,c%L.Sle% be/I <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> Disapproved I Sanitary Permit Fee(includes Groundwater a e Issued [as ' g Agent Signat (No Stamps) <br /> �q-� <br /> Approved ❑ Owner Given Initial Feel <br /> $)70`I 1.1 Surcharge <br /> Adverse Determin i / <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-8398(formerly Plb-67)(R.11/88) DISTRIBUTION: Original to County,One Copy To:Safety 8 Buildings Division,Owner,Plumber <br />