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ILHR SANITARY PERMIT APPLICATIONIn accord with ILHR 83.05,Wis.Adm.CodessssecouNTv <br /> rs0- <br /> �• N U <br /> STATESANITARY PERMIT#,Q0 jgog <br /> —Attach complete plans(to the county copy only)for the system,on paper not less than <br /> 8'%x 11 inches in size. El ch'k fre i� nto 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 /> rt A 11f '/4 #E Y4,S a 6 T N, R /Sr E(or)YD <br /> PROPERTY OWNER'S MAILING ADDRESS LOT# BLOCK# <br /> CITY,STATE vZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER <br /> vs e5 d Gosr3 NA <br /> 11. TYPE OF BUILDING: (Check one) ElState Owned VILLAGE_ F <br /> L a O /L 7t{ NEAREST ROAD <br /> ❑ Public ®1 or 2 Fam. Dwelling—#of bedrooms Z <br /> Ill. BUILDING USE: (If building type is public,check all that apply) 14— ;MD& �)— <br /> 1 ❑ ApVCondo <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. ❑ 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 /> 11 ® Seepage Bed 21 ❑ Mound 30 ❑ SpecityType 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 12.ABSORP.AREA 13.ABSOR, 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 /> 3 "° y g o 9 3, Feet 95. 0 Feet <br /> VII. TANK CAPACITY Site <br /> in allons Total #of Prefab. Fiber- Exper. <br /> INFORMATION New istin Gallons Tanks Manufacturer's Name oncret Con- Steel glass Plastic App <br /> Tanks Tanks strutted <br /> Se tic Tank or Holdina Tank 8 d o C D° 1f u <br /> Lift Pump Tank/Siphon Chamber <br /> Vill. 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 S mps) MP/MPRSW No.: Business Phone Number: <br /> SX tl'elrr <br /> Plumber's Ad ess(Street,City,State,Zip Code)' <br /> If y <br /> t / d # 5 ` ?13 <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved Sanitary Permit Fee(Includes Groundwater [DateIssued <br /> ssu Issuing Ag t SI tur ( Stamps) <br /> Approved ❑ Owner Given Initial 'Sri ne urcherpe Fee) <br /> v Determinati <br /> JJ VlJ _7A <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-8398(formerly Plb67)(R.11/88) DISTRIBUTION: Original to County,One Copy To:Safety&Buildings Division,Owner,Plumber <br />