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SANITARY PERMIT APPLICATION couNTv <br /> 70ILHA In accord with ILHR 83.05,Wis.Adm.Code bun,I�� <br /> �. �...,e. p ` <br /> STATE SANITAR PERMIT#/sl43(- <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than <�,r / <br /> 8fix11inches insize. ❑ Check if revisidn,topreviousapplication <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 PERTY OWN PROP RTY TION <br /> '4,S T N, R E (orW <br /> O ERTY OW 'S MAILING DDBESS O # BLOCK# <br /> IDX S --' <br /> .CITY, ATE • 1 ZIP CODE PHONE NUMBER <br /> 1V a 7: <br /> ll <br /> 11. TYPE OF BUILDING: (Check one) CITY f 5� NEAREST ROA <br /> ❑State Owned VILLAGE <br /> ❑ WW OF <br /> Public X1 or 2 Fam. Dwellingof bedrooms— A <br /> s L AX NUMBER( ) <br /> III. BUILDING USE: (If building type is public,check all that apply) 3, – spa q— O- <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. HYPE OF PERMIT: (Check only one in line A. Check line B if applicable) <br /> A) 1. ew 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5.El Repair of an <br /> ystem 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 El Mound 30 El Specify Type 41 El Holding Tank <br /> 2 eepage 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.AREA4. LOADING RATE 5. PERC.RATE 6. SYSTEM ELEV. 7. FINAL GRADE <br /> O RE U RED(sq.ft.) PRO SED(sq.ft.) (Gal /d /sq.ft.) (Min./inch) L.., ELEVATION <br /> B S r Feet Feet <br /> VII. TANK APACITV Site <br /> in allons Total #of Manufacturer's Name Prefab. Con- Steel Fiber- Plastic Exper. <br /> INFORMATION New istin Gallons Tanks oncret glass App. <br /> Tanks Tanks strutted <br /> Septic Tank or Holdino Tank Ism I ✓" <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:(IR stamps) MP/MPRSW No.: Business Phone Number: <br /> LIAOA <br /> ZG6 I!� <br /> lumber's Add esa(Otte it, i tate,zip code): <br /> IX. jCOUNTYIDEPARTMENTIUSE ONLY <br /> Lj Disapproved I Sanitary Permit Fee(Includes Groundwater a e esus Issuin Signature(No Stamps) <br /> pproved ❑ Owner Given Initial / -yS�urcharge Fee) = s <br /> A v rmin tion `O� 'ml `�'—� <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-8398(formerly Plb-67)F.11/88) DISTRIBUTION: Original to County,One Copy To:Safety&Buildings Division,Owner,Plumber <br />