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�ILHR SANITARY PERMIT APPLICATION �oDNT1� r <br /> e. <br /> In accord with ILHR 83.05,Wis.Adm.Code <br /> STATE NITARRMIT#in5il <br /> —Attach complete plans(to the county copy only)for the system,on paper not less than /i /��,�/��� <br /> 8%x 11 inches in size. ❑ C k f rl evlel 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 /> PROPERTY OWNER PROPERTY LOCATION <br /> '/s '/a, S T �, N, R 15 E(oifW <br /> PROPERTY OWNER'S MAILING ADDRESS LOT# BLOCK# <br /> D oRirNARp pV- f4 . — <br /> CITY,STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER <br /> KL 3 EE?I <br /> It. TYPE OF BUILDING: (Check one) CITY NEAREST ROAD <br /> State Owned �J VILLAGE <br /> ❑ PEEK fAIIA <br /> Public or 2 Fam. Dwelling–#of bedrooms` PARCEL TAX NUM ( ) <br /> III. 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. ❑ Replacement 3. ❑ Replacement of 4. ElReconnection 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 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) 7 ELEVATION <br /> Soo o �� 2, Feet 9 9 .© Feet <br /> CAPACITY <br /> VII. TANK Site <br /> in allons Total #of Prefab. Fiber- Exper. <br /> INFORMATION New istin Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App <br /> Tanks Tanks strutted <br /> Septic Tank orHoldin Tank `eSe/' <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): Plumber's Signature:(No mps) MPIMPRSW No.: Business Phone Number: <br /> o l 866- 5 <br /> umber's ddreas Wrist,City, tate,Zip Codel: I t /Q <br /> Z �o ry ln1Er>STc W I , Sq$I3 <br /> IX. COUNTY/DEPARTMENT US NLY <br /> ❑ Disapproved Sanitary Permit Fee(Includes Groundwater Date Issued Issuing Agent 'gnat re(No S ps) <br /> Approved ❑ Owner Given initials Surcharge Fee) <br /> Adverse /' <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 />