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ILHR SANITARY PERMIT APPLICATION <br /> tT s <br /> In accord with ILHR 83.05,Wis.Adm.Code COUNTY <br /> STATE SANITARY PERMIT# <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than <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 /> PRP ERTY OWNER PROPERTY LOCATION <br /> t �- )c�c s - ;:; 1/4 � '/4,S ` T_� /I NIR i:;_E (or)W <br /> PROPERTY OWNER'S MAILING ADDRESS "J'),, _,fes) / f l LOT# BLOCK# <br /> C'TY,STATE{ ZIP CODE �- PHO/NE NUMBERG( SUBDIVISION NAME OR CSM NUMBER <br /> G: (Check one CITY NEAREST ROAD <br /> 11. TYPE OF BUILDI <br /> ) State Owned VILLAGE:: C� <br /> Public ❑1 or 2 Fam. Dwelling-#of bedrooms— R&YAXNUM <br /> Ill. 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 ❑ RestauranVBar/Dining <br /> 4,0 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 2/0Replacement 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,e� 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. ABSO TION SYSTEM INFORMATION: <br /> 1.GALLONS ER 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) z gELEVATION <br /> �� �'2JFeet !- Feet <br /> VII. TANK CAPACITY Site <br /> in gallons Total #ofPrefab. Fiber- Exper. <br /> INFORMATION New isting Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App <br /> Tanks 1 Tanks structed <br /> Septic Tank or Holdinct Tank <br /> Lift Pump Tank/Siphon Chamber I Li- <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(P,nay: Plumber's Signatuns:-(NOttamps)i MP/M` S. No.: Business Phone Number <br /> �'.A/ .;5/f. ..-.�I //�l(�.�U<'.r� t_:/ 'Lir -\y ,L..:v_ ✓ i` <br /> Plumber's Address(Street,City,State,Zip Code): <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> Disapproved I Sanitary Permit Fee(Include Groundwater <br /> rouun,water a e Issued issuing Agent Signature(No Stamps) <br /> ❑Approved I Adverse❑ Owner Given Initial <br /> Determination <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(formerly Pib-67)(R.11/98) DISTRIBUTION: Original to County,One Copy To:Safety a Buildings Division,Owner,Plumber <br />