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�ILHR SANITARY PERMIT APPLICATION <br /> _ In accord with ILHR 83.05,Wis.Adm.Code COUN <br /> TY- <br /> ���• � STATE NITARY ERMIT# ' f7 <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than5q <br /> 8'%x 11 inches in size. 11 Check If r�Is to previous application <br /> -See reverse side for inst uctions for completing this application. STATE PLAN I.D.NUMBER <br /> I. APPLICANT INFORMA ION-PLEASE PRINT ALL INFORMATION. <br /> PROPERTY OWNER PROPERTY LOCATION <br /> Y4 ''/4, S T O , N, R IS- E(or <br /> PROPERTY OWNER'S MAILING kDDRESS LOT# BLOCK# <br /> O O c.H e • tJ 31 <br /> CITY,STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER <br /> It. TYPE OF BUILDING: ( ❑ State Owned <br /> heck Ona) CITY NEAREST ROAD `R <br /> VILLAGE'' V„ yp�r�- W <br /> ❑ Public �1 0 2 Fam.Dwelling-#of bedrooms— Nu <br /> 111. BUILDING USE: (If bu Iding type is public,check all that apply) <br /> 1 ❑ Apt/Condcr <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: (Clieck only one in line A. Check line Bit applicable) <br /> A) 1. 14 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 Per it was previously issued. Permit# _ Date Issued <br /> V. TYPE OF SYSTEM: ((heck only one) <br /> Non-Pressurized Distribution Pressurized Distribution Experimental Other <br /> 11 8 Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank <br /> 12 Seepage Trencl 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. BSORP.AREA 3.ABSORP.AREA 4. LOADING RATE 5. PERC.RATE 6. SYSTEM ELEV. 7. FINAL GRADE <br /> �/1 R OUIRED(sq.ft.) PROPOSED(sq.ft.) (Gas/day/sq.ft.) (Mi,n./Inch) ELEVATION <br /> 300 �'�' /'f'� .�� 3 Feet •l Feet <br /> CAPACITY <br /> VII. TANK Site <br /> in allons Total #of Prefab. Fiber- Exper. <br /> INFORMATION New Istin Gallons Tanks Manufacturer's Name ConcreteCon- Steel glass Plastic App <br /> Tanks Tanks strutted <br /> Septic Tank or Holdin Tank <br /> Lift Pump Tank/Siphon Champ <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:IN Stamps) MP/MPRSW No.: Business Phone Number: <br /> IG YJ (S <br /> Plumber's Address(Street,Ci State,Zip Code): <br /> 2-W6 ) . <br /> IX. COUNTY/DEPARTM USE ONLY <br /> Disappro ed Sanitary Permit Fee(Includes Groundwater Delta IssuedI u Agent ure(No Stamps) <br /> _ charge Fee) <br /> Approved ❑ Owner Gill eoD <br /> ,_�_G <br /> Adverse eterminatic <br /> X. CONDITIONS OF APPI IOVALIREASONS FOR DISAPPROVAL: <br /> , <br /> SBD-6398(formerly DISTRIBUTION: Original to County,One Copy To:Safety 8 Buildings Division,Owner,Plumber <br />