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Safetyuo{guildiMpve <br /> eurea washingtOn <br /> TION Pfllad°X 7 W 9537p7"7969 <br /> 'son. <br /> IT APPLICATION <br /> � <br /> SANITARY PERM Wis.Adm.code <br /> ILHR 83.05, County <br /> �� ►n accord vnth on p paper not less /i4 r� mit Number <br /> ap / lv <br /> Sanitary pe <br /> �'n r the system' State v=�'� onlyl fO to P1ewous aPP)�ca <br /> s(to the county copy <br /> IlcatlOn oGhe`k N r1 D Number (��-(�0 <br /> complete letingth►s State Plan Attach Comp t inches)n size. comp ap rams N,R LE lord <br />• $112 x for co encY Pro9 <br /> than coons ent ag N <br /> for InStrU by governor 8 ' <br /> See reverse ion y side IN? ALL INFORM�roP Oy Locator', /9 Block Number <br /> I.• used Y <br /> be <br /> ou Provide may SE 114 51/.1 <br /> inforh`ation Y 04 lt)(m)l O PI-Ep` PRINT tuber ,• <br /> The taws 15 ORMA?I N Lot Number 1€7 <br /> Ipri APPLICATION INF ame°r CS GS tuber Road <br /> Property p OWnvrName e.GL_E� SubdivisionN n Nearest <br /> Number A <br /> proPerty F �.1414r�gpddress �L�✓. Phone .. .�39, � qtyy /�/i l� <br /> yOwner PO�c.s Zip Code (G�! .• i11a9eOF/n F� 1 <br /> prop �E/ ,S'3 9/ - ❑State Owned 3 own Numbers) S so 8 <br /> to �/ one) edro s �- 'Parcel Tax �' 1 Facility <br /> city,state (check No.of b _ I 1 ationa <br /> B ✓ BUILrING• it Dwelli p " 1l thataPP►Y) �� D 10 ❑ Outdoor Recre Dining <br /> 11. ?YPE 1 or 2 Fam uo,c,check a t l gar I Car W ash <br /> Public a is P 11 ❑ Restaurant BUILDING USE: (If buildingtYP e 12 ❑ ServiceStation I Ca <br /> facility I Nursing H°m cify <br /> 111. BUILDING <br /> Medical Sa1es1 RePa)rs 13 ❑ Other: sPe <br /> 1 ❑ Apartment 1 Con 6 ❑ Merchandise n <br /> Hall 7 ❑ e Park applicable) <br /> Repair of 2 ❑ Assembly Mobile Home line B,if app of 5. ❑ Existing- <br /> 3.Factory Reconnection <br /> 3 ❑ Campground 9 0 Office I ox on stem <br /> 1 heck b S <br /> School line A. C entof 4. ❑ Existing y __---- <br /> 4 ❑ Church box On Rep _--_____ -- .. <br /> °tel!Motel onlyone __ i�+�I;J;� <br /> 5 ❑YpE Of PERMIT: (Check Replacement _-- 3_❑ Tank�n mbe�" <br /> IV• 136 New 2- ❑ System previously issued Permit Nu JUL 7 19 r <br /> Al System ___----- - re Tank <br /> --- Permit wasp Experimental Holding Tan <br /> ❑ p.Sanitary (Check only one) a 41 ❑ <br /> B) 30❑SPT 'OUnty EnvirOarlvy <br /> V TYPE OF SYSTEM: pressurized Distribution <br /> 21❑Mound Health Departt4i}�ault Privy <br /> Non-Pressurized Distribution 22❑In Ground pressure <br /> 11❑Seepage Bed <br /> 1 Seepage Trench <br /> 13❑Seepage Pit <br /> 14 0 System-In-Fill 4. Loading Rate 5.Perc.Rate 6. Syste Elev. 1. Final Gra <br /> INFORMATION Area Elevation <br /> VI. ABSORPTION SYSTEM r Area 3. Absorp. . Q8day/sq.te (Min./inch)5.Perc.R Rate 6. ys <br /> 2.Required P Proposed(sq.ft.) ( .r�/� /03•v Feet IG�-/si <br /> 1.Gallons Per Day ReQuired(sq ft.) A p_ <br /> �'�n 9w <br /> Capacity Total #of Manufacturer's time Prefab. Site Fiber- E <br /> Con- Steel Plastic <br /> VII. TANK in gallons Gallons Tanks Concrete strutted glass <br /> INFORMATION New Existin• <br /> Tanks Tanks �� "� ❑ � ❑ ❑ <br /> Septic Tank or Holding Tank L 7 , ❑ ❑ ❑ ❑ <br /> Lift Pump <br /> Tank/Siphon Chamber <br /> RESPONSIBILITY STATEMENT <br /> I,the undersigned,assume responsibility for installation of the onsite sewac stem shown on the attached plans. <br /> Plumber' •i.nature:(No Stamps) <br /> 1013•00.440.: Business Phone Number: <br /> # /1A • �a8'—f 7.�_ %3 <br /> Plumber's Name:(Print) <br /> Let v.,,.� 4J� <br /> Plumber's Address(S reet,City,State,,Zip Code : ` ■ <br /> I go ''►Ct 0 T USE ,a e ,fill <br /> Permit Fee (��c��eSGroundwaterrr. igna o Stamps) <br /> IX. COUNTY/DEP ' RTM Sanitary Surch.argelee) IU �, <br /> ❑Disapproved ,. s) <br /> pproved ❑Owner Given Initial <br /> Adverse Determination ��. <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br />