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ILHR SANITARY PERMIT APPLICATION COUNTY <br /> n accord r <br /> Id with ILHR 83.05,Wis.Adm.CodeEyj <br /> omm� <br /> • STATE NITAflERMIT# <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than J6�RY1 <br /> 8'%x 11 inches in size. [I Check if revla n to previous application <br /> —See reverse side for Instructions for completing this application. STATE PLAN I.D.NUMBER <br /> 1. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION. <br /> PROP TY OWNER PROPERTY LOCATION <br /> '/4 Y4, S T 10, N. R E(o W <br /> PROPERTY OWNER'S MAILING ADDRESS�v7� LOT BLOCK# I <br /> JI ' 10 11 1 <br /> CITY,STATE ZIP CODE IPIONENUMBER SUBDIVISION NAME OF)CSM NUMBE13 <br /> AD- <br /> IL TYPE OF BUILDING: (Check one) [I State Owned VILLAGERX <br /> NE EST�RO <br /> ❑ Public M 1 or 2 Fam. Dwelling-#of bedrooms ELTAX ( ) <br /> 111. BUILDING USE: (If building type is public,check all that apply) 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 2,4Replacement 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 ElSpecify Type 41 EJ 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 13.ABSORP.AREA 4. LOADING RATE 15. PERC,RATE 6. SYSTEM ELEV. 7. FINAL GRADE <br /> /^ REQUIRED(sq.ft.) PR POSED(sq.ft.) (Gals/day/sq.ft.) (Min./inch) ELEVATION <br /> 125. 01 Feet Feet <br /> VII. TANK CAPACITY Site <br /> in al Ions Total #of Prefab. Fiber- Exper. <br /> INFORMATION New xistin Gallons Tanks Manufacturer's Name oncrete Con- Steel glass Plastic App <br /> Tanks Tan strutted <br /> Septic Tank or Holdin Tank <br /> Lift Pump Tank/Siphon Chamber <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 mps) MP/MPRSWNo.: Business Phone Number: <br /> 9I S <br /> Plumber's Address(street City,,,State,NTltp Cod :� �(Q�IZ V J <br /> COUNTY//D/DEPARfrTOMENTTLUl1SE ONLY <br /> Gv IJI�OEf2J <br /> ❑ Disapproved Sanitary Permit Fee(Includes Groundwater a e Issued Issuing Ag n ign re ps) <br /> ,�,iS-u�rcharge Feel <br /> Approved ❑ Owner Given Initial o vV <br /> Adverse Determination <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-8399(formerly Plb-67)(R.11/89) DISTRIBUTION: Original to County,One Copy To:Safety&Buildings Division,Owner,Plumber <br />