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�,ILHFI SANITARY PERMIT APPLICATION ooDN�v <br /> In accord with ILHR 83.05,Wis.Adm.Code {y, <br /> STATE NITARY RMIT#ILCr�g3 <br /> —Attach complete plans(to the county copy only)for the system,on paper not less than 11s���) <br /> 8%x 11 inches in size. Check if revisloffto 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 OWN: PROPERTY LOCATION <br /> Q f /a A/i,S Tag , N, R /4 W <br /> ROPE TY OWNER'S SIAILING ADDRESS LOT# BLOCK# <br /> 7 <br /> ZIP CODE / PHONE NUMBE 3 SUBDIVISION NAME OR CSM NUMBER <br /> 11 CITY _T <br /> II. TYPE OF BUILDING: (Check one) ❑StateOwnedVILLAGE : NEAREST RO D n <br /> ly <br /> El Public �1 or 2 Fam. Dwelling—{k of bedrooms PAR NUMBER( I'NAr/ <br /> 111. BUILDING USE: (It 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.X 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 /> 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 2.ABSORP.AREA 3.ABSORP.AREA 14. LOADINGRATE 5. PERC.RATE 16. SYSTEM ELEV. 17. FINAL GRADE <br /> //�� <br /> CC � Q REQUIRED(sq.ft.) PROPOSED(sq.ft.) (Gals/day/sq.ft.) (Min./inch) P ELEVA ION <br /> 1155 ;Z--"5/5 Feet 9 ��/ Feet <br /> VII. TANK CAPACITY Site <br /> in allons Total #of Prefab. Fiber- Exper. <br /> INFORMATION New istin Gallons Tanks Manufacturer's Name c et Con- Steel glass Plastic App <br /> Tanks Tanks strutted <br /> Se tic Tank or Holding 0 0 d <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): Plum r' Signal re:(No Stam MP/MPRSW No.: Business Phone Number: <br /> ExV�eti it 5�1�; c <br /> Ply bar's Address Street,City,State,Zip Code): <br /> /�'I 40 S� < -7 q- gr 7 <br /> IX./COUNTY/DEPARTMENT USE ONLY <br /> Disapproved Sanitary Permit Fre�r(IucnerFej water <br /> ssuingAgen eurNoSm )Srarpee <br /> Approved ❑ Owner Given initial 74YIo7 <br /> Adverse Determination <br /> l <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(formerly Plb-67)(R.11/88) DISTRIBUTION: Original to County,One Copy To:Safety&Buildings Division,Owner,Plumber <br />