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SLPILHR SANITARY PERMIT APPLICATION <br /> In accord with ILHR 83.05,Wis.Adm.Code c`- • <br /> —Attach complete plans(to the county copy only)for the system,on paper not less , `' - 7 <br /> 8%x 11 inches in size. <br /> STAT SANITARY PERMIT# <br /> 0 than <br /> —See reverse side for instructions for completing this application. / ���R <br /> Check if revision to previous application <br /> I. APPLICANT INFORMATION—PLEASE PRINT ALL INFORMATION. STATE PLAN I.D.NUMBER <br /> PR•• • OWNER <br /> 1 ' rqC -17 5, <br /> G b�Git~"T ? PROPERTY LOCATION <br /> 1 G <br /> PROPERTY OWNER'S MAILING ADDRESS <br /> C� ` `�+S T 7, N, R <br /> .. O _ AI y . 14"- LOT# 9 BLOCK# / E(Or) <br /> ZIP CODE PHONE NUMBER � " <br /> ? SUBDI`SVISION, p UMBER <br /> . TYPE OF BUILDING: (Check one) -� . .., • <br /> 0 ) ❑State Owned NEAREST ROAD <br /> Public 1 1 or 2 Fam.Dwellin • • • iv ���_ S ��y <br /> Of bedrooms AR L AX NUMBER( <br /> M. BUILDING USE: (If building type is public,check all that apply) O ` ._ O 7// <br /> 1 ❑Apt/Condo �� —5 3�'_ <br /> 2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home / <br /> 3 ❑ Campground g 10 ❑ Outdoor Recreational Facility <br /> 7 ❑ Merchandise: Sales/Repairs 11 ❑ Restaurant/Bar/Dining <br /> 4 0 Church/School 8 0 Mobile Home Park <br /> 5 ❑ Hotel/Motel 9 ❑ Office/Factory 12 ❑ Service Station/Car Wash <br /> IV. TYP OF PERMIT: (Check only one in line A. Check line B if applicable) 13 ❑ Other: Specify <br /> A) 1. New 2. ❑Replacement 3. ❑Replacement of 4. <br /> System System Tank O ❑ Reconnection of 6 5.❑Repel,ppf an <br /> y Existing System O,� xlstl> ystem <br /> B) 0 A Sanitary Permit was previously issued. Permit# <br /> V. TYPE OF SYSTEM: (Check only one) Date Issued . N■ � el <br /> Non-Pressurized Distribution Pressurized Distribution Experimental O'�, L� 46 <br /> 11 • eepage Bed 21 0 Mound �,p `.9 <br /> 12 ► Seepage Trench 30 ❑ Specify Type 41 <br /> 22 ❑ In-Ground d�ol Privy Tank <br /> 13 a Seepage Pit 42 j Privy <br /> 14 ❑ System-In-Fill Pressure <br /> 43 ' a#Privy <br /> VI. ABSORPTION SYSTEM INFORMATION: O/ <br /> 1.GALLONS •-ER DAY 2.ABSORP.AREA 3.ABSORP.AREA 4. LOADING RATE 5. PERC.RATE <br /> A i A REQUIR��q.ft.) PROPOSED(sq.ft.) (Gals/day/-q.ft.) (Min./inch) 6. SYSTEM ELEV. 7. FINAL GRADE <br /> / 7S-0 g ELEVATION <br /> VII. TA CAPACITY /T + ` <br /> Feet .0 Feet <br /> INFORMATION in 'allons Total #of Site <br /> New istin• Gallons Tanks Manufacturer's Name Prefab. Con- Steel Fiber- Exper. <br /> Tanks Tanks <br /> oncret structed glass Plastic <br /> Se•tic Tank or Holdln•Tank �`�_ <br /> App. <br /> Lift Pum•Tank/Si oldln•Chamber �.i/ .`■■■■■■■.■■■■■.■■ <br /> r� ,.Sd ■■■7�7r�■-■7 ■ <br /> VIII. RESPONSIBILITY STATEMENT r' <br /> I,the undersigned,assume respo sibility for installation of ,: onsite sewa system shown on the attached plans. <br /> (No Sta�•• <br /> IdE/MPRSW No Business Phone Number: <br /> 1[�I. <br /> _ 4 �c©ity State, C•paw, .-, - /tQE)r� J� <br /> /i P de. 7 ,1� , f. 6 <br /> VIA di jar- ■IX. COUNTY/DEPART EN USE • ,5'"/ p <br /> ��((� ❑ Disapproved Sanitary Permit Fee(Includes Groundwater <br /> EL ►pproved ❑ Owner Given Initial Surcharge Fee) 'a e slue• Issuin• •e• o Stamps) <br /> Adverse Determination ) 3 ,),3 CJ c, "... <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> BD-6398(formerly PIb-67)(R.11/88) DISTRIBUTION: Original to County,One Copy To:Safety&Buildings Division,Owner,Plumber <br />