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�ILHR SANITARY PERMIT APPLICATION <br /> In accord with ILHR 83.05,Wis.Adm.Code couNTv <br /> — s $u-RNcT <br /> STATE SANITAR ERMIT <br /> –Attach complete plans(to the county copy only)for the system,on paper not less than <br /> 8'%x 11 inches In size. ❑ Check If revis' 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. S�PROPERTY OWNER P�PE'R <br /> ATION <br /> AIF_X., S T N, R E (or W <br /> PROPERTY OWNER'S MAILING ADDRESS BLOCK <br /> 20 ( LCITY,STATE ZIP CODE PHONE NUMBER Cfl <br /> k e5 <br /> II. TYPE OF BUILDING: (Check one) NEAREST ROAD <br /> ❑ State owned MiL IN ZO <br /> Public 1 or 2 Fam. Dwelling—#of bedroomsL NUM <br /> Ill. 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 ❑ 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.XReplacement 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.ABSORP.AREA 14. LOADING RATE 5. PERC.RATE 6. SYSTEM ELEV. 7. FINAL GRADE <br /> REQUIRED(sq.ft.) PROPOSED(sq.ft.) (Gals/day/sq.ft.) (Min./inch) ELEVATION <br /> Feet Feet <br /> CAPACITY <br /> VII. TANK Site <br /> allons Total #Of Prefab. Fiber- Exper. <br /> INFORMATION <br /> Fin <br /> ew istin Gallons Tanks Manufacturer's Name oncret Con- Steel glass Plastic Appnks Tanks structed <br /> Septic Tank or Holding Tank COO Vic, 1IC�LLj <br /> Lift Pump Tank/Siphon Chamber <br /> Vlll. 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 mpaI MP/MPRSW No.: Business Phone Number: <br /> 6D RrGK pyjns - Q�o59 �lS (� � IS7 <br /> Plumber's Address(Stree City,State,Zip Code): <br /> 7 lsac7 vi 35 uiEBf;TER— WI . 547)92, <br /> IX. COUNTY/DEPARTME T USE ONLY <br /> ❑ Disapproved Sanitary Permit Fee(Includes Groundwater Date Issued Issuing Art Signature(No Stamps) <br /> XApproved ���...FFF _ Suroharge Fee) <br /> ❑ Owner Given Initial cyt lo� u�o <br /> Advrmin ion —71' <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(formerly Plb$7)(R.11/88) DISTRIBUTION: Original to County,One Copy To:Safety&Buildings Division,Owner,Plumber <br />