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��ILHR SANITARY PERMIT APPLICATION <br /> In accord with ILHR 83.05,Wis.Adm. Code cou rr <br /> ���• STATE SANITARY PERMIT# I372.Z4 <br /> —Attach complete plans(to the county copy only)for the system,on paper not less than (_(k,%Tsq) <br /> 8'%X 11 Inches In size. ❑ Check if revision to 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 /> PROP RTY OWNER PROPERTY LOCATION <br /> Z6,21 T N, R E (or <br /> PROP TY OWN R'S MAILIN ADDRESS LOT# BLOCK# <br /> O <br /> Ca,STATE ZIP C E PHONE NUM ER SUBDIVISION NAM OR CS NUMBER <br /> It. TYPE OF BUILDING: (Check one) CITY NEAREST ROAD <br /> ❑ State Owned VILLAGE S� tlN QF � <br /> ❑ Public 1 or 2 Fam. Dwelling—#of bedroomsPARCEL TAX NU\M/t ( ) ✓/C <br /> Ill. 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. El Replacement 3. ❑ Replacement of 4. El Reconnection of 5.El 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 13.ABSORP.AREA 4. LOADING RATE 5. PERCRATE 6. SYSTEM ELEV. 7. FINAL GRADE <br /> REOUIR D(sq.ft.) PROPOSED(sq.ft.) (Gals/day/sq.ft.) (Min./inch) (� LEVATION <br /> 3 d Feet 190 <br /> Feet <br /> VII. TANK CAPACITY Site <br /> in allons 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 Holdin Tank <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:tihD Stamps) MP/MPRSW No.: Business Phone Number: <br /> Plum is Address(Street,City,Ptate,Zi Code <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑ Surcharge Fee)Disapproved Sanitary Permit Fee(Includes Groundwater Date IssuedIs I Agent Signa (No Stamps) <br /> Approved ❑ Owner Given Initial �S a u <br /> A v rite D min ti n 'T` <br /> 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 />