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-ILHR SANITARY PERMIT APPLICATION <br /> In accord with ILHR 83.05,Wis.Adm. Code couNTv <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than (/)4Wq I <br /> 8'%x 11 inches in size. ❑ Check if revisiop4o 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 /> P OPERTY OWNER PROPERTY LOCATION <br /> /C a, Sc3L _7 <br /> , N, R / W <br /> FIiOPERTY O NE�MAOILING ADD SS LOT BLOCK# <br /> 6�J S � V <br /> C ,ST TE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR SM NUMBER <br /> .e pN y3 '7 <br /> CITY NEAREST ROAD <br /> II. TYPE OF BUILDING: (Check one) ❑ State Owned VILLAGE, df <br /> [] Public ©1 or 2 Fam. Dwelling-#of bedrooms PA EL AX NU/M R( ) '&41 Coe,n trnt;�.o / O Hd <br /> III. BUILDING USE: (If building type is public,check all that apply) <br /> 1 ❑ ApVCondo <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. ❑ 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 ® 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 PE2.ABSORP.AREA 3.ABSORP.AREA 4. LOADING RATE 5. PERC.RATE 6. SYSTEM ELEV. 7. FINAL GRADE <br /> REQUIRED(sq.ft.) PROPOSED(sq.ft.) (Gals/day/sq.ft.) (Min./inch) �y ELLEVION <br /> R DAY <br /> U00 G 30 G 3 a • �G 9Sr Feet /7 7/ Feet <br /> CAPACITY Site <br /> VII. TANK in allons Total #ofPrefab. Fiber- Exper. <br /> INFORMATION New !stingGallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App <br /> Tanks Tanks OL strutted <br /> Septic Tank or Ho ldin TenIr- ran <br /> Lift Pump Tank/Siphon Chamber 0 I SOO <br /> VIII. RESPONSIBILITY STATEMENT CoMw"fO 10N_ <br /> I,the undersigned,assume responsibility for installation of the onsite sewage system shown on the attached plans. <br /> Plumber's Name(Print): P Signet re:(No mps) MPHArRSYyR '" Business Phone Number:: <br /> ate/ (T 0h d75� f /� � 4b SSS <br /> Plum er's Address(Street,City,State,Zip Code): <br /> RT ( Uc rI AP% <br /> I& COUNTY/DEPARTMENT USE ONLY 1/7 <br /> EJ Disapproved Sanitary Permit Fee(Inciudes oraundweter ee ssu Issui gent Signe 0Stamp;) <br /> $umharpe Fee) <br /> Approved ❑ Owner Given Initial IC6. 00 -',� <br /> Adverse term'n tion <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 8 Buildings Division,Owner,Plumber <br />