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laDILHR SANITARY PERMIT APPLICATION <br /> In accord with ILHR 83.05,Wis.Adm. Code COUNTY <br /> �-• r <br /> STATES TARY MIT#'1nrf�Q <br /> –Attach complete plans(to the county copy only)for the system,on paper not less than <br /> �74� OtJ / O <br /> 8'%x 11 inches in size. ❑ rr Check If revisio o 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 LOCATION <br /> %a ''/a,S T N, R E (o W <br /> PROPERTY OWNER'S MAILING ADDRESS LOT# BLOCK# <br /> -5.g <br /> CITY,STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR SM NUMBER <br /> LID' E 5 Z lZ 11Z')L26 <br /> IL TYPE OFWILDING: (Check one) ❑State Owned Li CITTY NEAREST ROAD <br /> [] Public Ip t or 2 Fam. Dwelling,#of bedrooms 2 A. <br /> III. BUILDING USE: (If building type is public,check all that apply) OC��JS Oa-`7CFb <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 ❑ RestauranUBar/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. ElReplacement of 4. ElReconnection 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 /> 11Seepage Bed 21 ElMound 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 1 2.ABSORP.AREA 3,ABSORP.AREA 4. LOADING RATE 5. PERC.RATE 6. SYSTEM ELEV. 7. FINAL GRADE <br /> REO IRED(sq.ft.) PROPOSED(sq.ft.) (Gals/day/sq.ft.) (Min./inch) ELEVATION <br /> 300 (oZ b Feet CitS Feet <br /> VII. TANK CAPACITY Site <br /> in as Ions Total #of Prefab. Fiber- Exper. <br /> INFORMATION New istin Gallons Tanks Manufacturer's Name ConcreteCon- SteelJglass Plastic App. <br /> Tanks Tanks structed <br /> Septic Tank or Holding Tank <br /> Lift Pump Tank/Si hon Chamber <br /> VIII. RESPONSIBILITY STATEMENT <br /> I,the undersigned,assume responsibility for installation of the onsite sewage system shown on the attached plans. <br /> Plumber's Name(Print): Plumber's Signature:( tamps) MPMP SW�o.: Business Phone Number: <br /> 47 1 <br /> RKARRr) IS <br /> S(001s� <br /> Plumber's Address(Street,City,State,Zip Code): <br /> 2'7IGO 9 WIESR i 893 <br /> IX. COUNTY/DEPARTMENT U ONLY <br /> ❑ Disapproved Sanitary Permit Fact(Includes Groundwater a e Issued s in <br /> _ Surchar eFee 9 gent Signature(No Stamps) <br /> Approved ❑ Owner Given Initial r}' /�S • g I <br /> A rmin I n —1? "l/ <br /> X. ONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> .77 77- <br /> SBD-6398(formerly Plb-67)R.11/88) DISTRIBUTION: Original to County,One Copy To:Safety&Buildings Division,Owner,Plumber <br />