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r _ ., <br /> DILH d SANITARY PERMIT APPLICATION <br /> ..... D H In accord with ILHR 83.05,Wis.Adm.Code COUNTY n Ly <br /> STATE SANITARY PERMIT# <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than 3 27) j� <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. / /i'7‘ ,-=. 3- <br /> PROPERTY OWNER /) i PROPERTY LOCATION <br /> (64...1,4_,/ -t .J , 5Z % NE 'A, S 13 T e , N, R /Z- E ( W <br /> PROPERTY OWNER'S M ING DRESS LOT# BLOCK# <br /> 475 ,(a. �3� / <br /> CITY,STAT �9 �, /� ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER <br /> r74" =� -C l2L/ 3-35-3? ( a? )GAS S?‘‘ /6"e-t, <br /> II. TYPE OF BUILDING: (Check one) ❑ CITY NEAREST OAD ' <br /> ❑State Owned VILLAGE FYI Pj— /Cdi li❑ Public X11 or 2 Fam. Dwelling–#of bedrooms.'PARCEL TAX NUMBER(S) <br /> III. BUILDING USE: (If building type is public,check all that apply) /8-- QLs)2— 33 / - 7/00 - l f <br /> 1 ❑ Apt/Condo <br /> 2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility <br /> 3 ❑ Campground 7 ❑ Merchandise: Sal /Repairs CO ❑ Restaurant/Bar/Dining <br /> 4 ❑ Church/School 8 ❑ Mobile Home Park�Q UFC �� Service Station/Car Wash <br /> 5 ❑ Hotel/Motel 9 ❑ Office/Factory A, Co <br /> / 1 Other: Specify <br /> IV. TYPE OF PERMIT: (Check only one in line A. Check line B if applicable) O'45�1J.'(e. /�,4 <br /> h <br /> A) 1.SA New 2. ❑ Replacement 3. ❑ Replacement of 4. t? �t ,Etnection of 5.❑ Repair of an <br /> System System Tank Only �f9tSystem Existing System <br /> B) ❑ A Sanitary Permit was previously issued. Permit# — ?fate�f ued <br /> V. TYPE OF SYSTEM: (Check only one) <br /> Non-Pressurized Distribution Pressurized Distribution Experimental Other <br /> 11 Seepage Bed 21 El 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. PERC.RATE 6. SYSTEM ELEV. 7. FINAL GRADE <br /> REQUIRED(sq.ft.) PROPOSED(sq.ft.) (Gals/day/sq.ft.) (Min./inch) ,rwv&1 R - jce..3 ELEVATION <br /> /g /9GC a, o, St _ . 6 / t7 0 `/c Let <br /> VII. TANK CAPACITY Site <br /> in gallons Total ##of Prefab. Fiber- Exper. <br /> INFORMATION New Existing Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic <br /> App. <br /> Tanks Tanks structed <br /> Septic Tank or Holding Tank CIO fAIPeQ / f J /7 ® ❑ ❑ ❑ ❑ ❑ <br /> Lift Pump Tank/Siphon Chamber IIrO Om / ,2 c- 2 ❑ ❑ ❑ ❑ _ ❑ <br /> VIII. RESPONSIBILITY STATEMENT <br /> I,the undersigned,assume responsibility for installation of the onsite sewage system shown on the attached plans. <br /> Plum�jbb is a e(Print): / Plumber' Sig ature:(No Stam IM /P/MPRSW N Business Phone Number.&&) L A- ' ('j//i )�i d~ � 4 T" <br /> Plum 7:2(Street,City,State,Zip Code): <br /> Sri-C., /5/S (o&4-0Asied, � l a-i; 536-?,/ <br /> IX. COUNTY/DEPARTMENT USE ONLY / J <br /> ❑ Disapproved Sanitary Permit Fee(Includes Groundwater .Date Issued I ent_S'a natu o tamps) <br /> �� Surcharge Fee) <br /> Approved ❑ Owner Given Initial ^ / //'LIA .,7/ ■,∎4 <br /> Adverse Determination •`v / ' �� <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: ei cze4 <br /> }F f 'Ct_(y) Wairc 1nP.. <br /> --Frz s�a 4"- L O G. 3 -tre. 4t 6« <br /> w.L r- .0 <br /> SBD-6398(formerly Plb-67)(R.11/88) DISTRIBUTION: Original to County,One Copy To:Safety&Buildings Division,Owner,Plumber <br />