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DILHR SANITARY PERMIT APPLICATION <br /> couNTv <br /> In accord with ILHR 83.05,Wis. Adm. Code + � <br /> , <br /> l� l <br /> STATE 5ANITARY PERMIT#l�)S fJJ <br /> —Attach complete plans(to the county copy only)for the system,on paper not less than (b3 <br /> 8'%x 11 inches in size. 11Check if revisio,,,,,,((o 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 /> PROPERTY OWNER PROPERTY LOCATION / <br /> ILLI5 '50FC. —� '%,S T , N, R E(O W <br /> PROPERTY OWNER'S MAILING ADDRESS LOT# BLOCK# <br /> ( U)EW Lnj .. 32 hffl <br /> CITY,STATE I ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER <br /> CK►`tSKfl �63f$ R c1N5 w ?wEs <br /> II. TYPE OF BUILDING: (Check one CITY NEAREST ROAD <br /> State Owned VILLAGE JQWN RF: �� �111�1r) RISER �(� <br /> ❑ Public 1 or 2 Fam. Dwelling,#of bedrooms EL x O 1, <br /> 111. BUILDING USE: (If building type is public,check all that apply) - V _�/3 � Oq— az <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: (Chet 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 /> 11SeepageBed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank <br /> 12 1K 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 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) ELEVATION <br /> � 20 20 • 6 3 LIS Feet 49 ,0 Feet <br /> VII. TANK CAPACITY Site <br /> in %lions Total #of Prefab. Fiber- Exper. <br /> INFORMATION New istin Gallons Tanks Manufacturer's Name oncrete Con- Steel glass Plastic App <br /> Tanks Tanks strutted <br /> Septic Tank or Holdino Tank f. <br /> Lift Pump Tank/Siphon 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 tamps) MP/MPRSW No.: Business Phone Number: <br /> Plumber's Address(Street,City,State,Zip Code): <br /> Z? (&o Hw5-5 W051 L")I . 5448,33 <br /> IX. COUNTY/DEPARTME USE ONLY <br /> Disapproved Sanitary Permit Fee(Includes Groundwater Date Issued Issuing A e t ignat re(No S mps) <br /> Approved ❑ Owner Given Initial Surcharge Fee) <br /> A v rse Determin i n —4 I <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6399(formerly Plb-67)R.11/88) DISTRIBUTION: Original to County,One Copy To:Safety 8 Buildings Division,Owner,Plumber <br />