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, SANITARY PERMIT APPLICATION <br /> LHR COUNTY <br /> In accord with ILHR 83.05,Wis.Adm.Code OM 6 a9-0 r7 <br /> STATE SANITARY PERMIT# <br /> —At#ach complete plans(to the county copy only)for the system,on paper not less than / 91 <br /> 8'A x 11 inches in size. Check if revision top sous application <br /> —See reverse side for instructions for completing this application. STATE PLAN I.D.NUMBER <br /> I. APPLICANT INFORMATION—PLEASE PRINT ALL INFORMATION. /3 $ ci ©88' <br /> PROP W'TY OWNS PROPERTY LOCATION <br /> L.)/911/4./ �U/ n1G Ai 'A siA)'A, S 5-- T S, N, R 9 E <br /> PROPERTY OWNERV4AILING DRESS LOT# 2 BLOCK# <br /> 2Aty/ /C6o-.1- /vi. Cr-. <br /> CIp)STATE ZIP CODE PHONE NUMBER CSM NUMBER <br /> Ji)47ff, C Si 15390/ I( ) CSM S 34, <br /> D CITY NEAREST ROAD <br /> II. TYPE OF BUILDING: (Check one) E]State Owned !1 VILLAGE O �o,`/ I 5 k 72214/412,4.6 <br /> ❑ Public t411 or 2 Fam.Dwelling—#of bedroomsZ_ PAR NUMBER(Si <br /> III. BUILDING USE: (If building type is public,check all that apply) 05'73 - a/0(.3-7L <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. x New 2. ❑Replacement 3. ❑Replacement of 4. ❑ Reconnection <br /> 5.'94 Repair of a h <br /> System System Only Existing System l R#5,,, On ,, <br /> l <br /> B) ❑ A Sanitary Permit was previously issued. Permit# _ Date Issued <br /> !1 <br /> V. TYPE OF SYSTEM: (Check only one) X1 to <br /> Non-Pressurized Distribution Pressurized Distribution Experimental Other %��, p <br /> 4 <br /> 11 Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Hol'�gTank <br /> 12 Seepage Trench 22 ❑ In-Ground 42 ❑ Pit Iv <br /> 13 Seepage Pit Pressure 43 ❑ VaultPrik <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 <br /> GRADE <br /> REQUIRED(sq.ft.) PROPOSED(sq.ft.) (Gals/day/sq.ft.) (Min./inch) ELEVATION <br /> 6'00 /20o /2.€2e, •S ✓./ <br /> 95;512/ Feet 9g.0 l Feet <br /> VII. TANK CAPACITY Site <br /> in gallons Total #of Prefab. Fiber- Exper. <br /> INFORMATION New fisting Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App <br /> structed <br /> Tanks Tanks ,p ❑ ❑ <br /> Septic Tank er+leldin¢Tank /0°O /2.4P O / 4/figs & ' ® ❑ <br /> Lift Pump TanWBiph,rtehamber" �l7 / �/ �� ® ❑ ❑ - ❑ <br /> VIII. RESPONSIBILITY STATEMENT <br /> I,the undersigned,assume responsibility for installation of the onsite sewage system shown on the attached plans. <br /> Plum is Name(Print): Plum '? Signature:(No tam MP/MPRSW s No.: Business Phone Number: <br /> yv� 3-z6 (per ) .2 71-6, "i <br /> Plum rasa(Street,City,State,Zip Code):; /� W r �2 �T 44.170/50,•0 <br /> GJ 5_ S-37/3 <br /> j <br /> IX. <br /> COUNTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved Sanitary Permit Fe (Includes Groundwater �D at !saved g <br /> Agent Signet o Stamp4 s) <br /> Approved ❑ Owner Given Initial 9�-u geAr <br /> Adverse Determination <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> e.e„cone,......._.k,DlIslal ra 1l/RAt nISTRIBUTION: Oriainal to County,One Copy To:Safety&Buildings Division,Owner,Plumber <br />