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�ILHR SANITARY PERMIT APPLICATION <br /> In accord with ILHR 83.05,Wis.Adm.Code COUNTY <br /> — s RN t✓T� <br /> STATES NITARY p��gMIT#)-7,J� <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than 17k3 <br /> 8'%x 11 inches in size. ❑ Check If revisi000aaafffo 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 /> PROPERTY OWNER PROPERTY L ATION <br /> 1 ) E '/as W '/4, S I5 T , N, R E (o W <br /> PROPERTY OWNER'S MAILING ADDRESS LOT# BLOCK# <br /> IAw 3 N)l -9 <br /> CITt1',STATE ZIP CODE PHONE NUMBER SU Acro <br /> IL.] ITYIS.ITYPEEvOFBUILDING: (Checkone) ❑ State Owned VILLAGE: LrV !� NEAREST ROAD <br /> . L1Nc.o� �HoTK �• <br /> ElPublic 1 or 2 Fam. Dwelling-#of bedrooms Z Ax Nu <br /> III. BUILDING USE: (If building type is public,check all that apply) >�-.3q Is—0 3) <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. ❑ Replacement of 4. ❑ Reconnection of 5.❑ Repair 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 ❑ 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.ASSORP.AREA 4. LOADING RATE 5. PERC.RATE 6. SYSTEM ELEV. 7. FINAL GRADE <br /> RE RED AREA <br /> ft.) PROPOSED(sq.ft.) (Gals/day/sq.ft.) (Min./inch) (� ELEV�AjTION <br /> 30 eoG .(o -I 7 Feet O Feet <br /> VII. TANK CAPACITY Site <br /> N' <br /> allona Total #of Prefab. Fiber- Expp. <br /> INFORMATION New istin Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App <br /> Tanks Tanks l strutted <br /> Septic Tank or Holdina Tank SO01 - N <br /> Lift Pump Tank/Siphon Chamber <br /> 777 <br /> VIII. RESPONSIBILITY STATEMENT <br /> 1,the undersigned,assume responsibility for installation of the onsite sewage system shown on the attached plans. <br /> Plumber's Name(Print): Plumber's Signature:(No Stamps) MP/MPRSW No.: Business Phone Number: <br /> ICA19919 Itrs <br /> Plumber's Address(street,City,State,Zip Code): <br /> _72,11b 0 h 35 WFBSTCR w i % <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved Sanitary Permit Fee(fecludee ess <br /> Groundwater aue Issuing Sig tura tamps) <br /> ,,y <br /> Approved F-1 Owner Given Initial los s DoSurcharge Fee) 7a-"/ _.,ll 1 Lai <br /> Adverse Det <br /> rmin tion <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&Buildings Division,Owner,Plumber <br />