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DILHR SANITARY PERMIT APPLICATION <br /> In accord with ILHR 83.05,Wis.Adm.Code couNTv <br /> STATE SANITARY1kERMIT#Jn�3,� <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than <br /> CLif 11 inches in Size. ElCh if revision 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 /> 1 \,J Ya,S Z-, T 16, N, R 11 E (O W <br /> PROPERTY OWNER'S MAILINGADDRESS_I <br /> ZIPCODE LOT# BLOCK# <br /> CITY,STATE 3 .•iL77E PHONE NUMBER <br /> �k ( Z6 , I flCR� <br /> It. TYPE F BUILDING: (Check one CITY NEAREST ROAD <br /> State Owned'�� VILLAGE - 'QL1fcf 14 aL)_ <br /> ❑ Public or 2 Fam. Dwelling-#of bedrooms — PA L Ax LTty <br /> III. BUILDING USE: (If building type is public,check all that apply) <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 B ❑ Mobile Home Park 12 ❑ Service Station/Car Wash <br /> 5 ❑ Hotel/Motel 9 ❑ Office/Factory 13 ❑ Other: Specify <br /> IV. TYPE OF PERMIT: (Chet my 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 7[J Seepage Bed 21 El Mound 30 ❑ Specify Type 41 El Holding Tank <br /> 1 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.ABSORP.AREA 14. LOADING RATE 15. PERC.RATE 6. SYSTEM ELEV. 17. FINAL GRADE <br /> REQ IRED(sq.ft.) PROPOSED(sq.ft.) (Gals day/sq.ft.) (Min/inch) ELEVATION <br /> 30 o O to .(? Feet Feet <br /> VII. TANK CAPACITY Site ' <br /> in gallons Total #of Prefab. Fiber- Exper. <br /> INFORMATION New istin Gallons Tanks Manufacturer's Name Con re Con- Steel glass Plastic App <br /> Tanks Tanks strutted <br /> Septic Tank or Hold ng Tank �' Q <br /> lift Pum 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: No S mps) MP/M`PR`SW No.: Business Phone Number: <br /> C 7 6- <br /> P m er's Address(Street, i ,State,Zip Cod <br /> '1'1 b o vrj SIB 55�1Z t,J t . S' t8 � <br /> Z <br /> X. OUNTY/DEPARTMENT USE ONLY <br /> Disapproved Sanitary Permit Fee(Includes Groundwater te Issued Issuing A ent Signature(No mps) <br /> Approved F-1ownerGiven Initial ,G <br /> Adverse Determination J surcharge Fee) v cT / <br /> X. C DITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6393(formerly Plb-67)(R.11/88) DISTRIBUTION: Original to County,One Copy To:Safety&Buildings Division,Owner,Plumber <br />