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713ILHR SANITARY PERMIT APPLICATION <br /> o In accord with ILHR 83.05,Wis.Adm.Code COUNTY <br /> ✓ <br /> r <br /> • �_ STATE SANITARY P�MIT#)01?3 , I <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than (IL-1 b( P T <br /> 8%x 11 inches in size. ❑ Check Ifrevision 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 /> PROP OWNER PROPERTY L ATION <br /> yv '/a E'/a,S /a T N, R �S E (or <br /> PROP OW R'S MAILING ADDRESS LOT# BLOCK# <br /> Tawla <br /> CITY,rST�E v /07& ZIP CODE Y. <br /> PHONE NUM ER SUBDIVISION NAME OR CSM NUMBER <br /> II. TYPE OF BUILDING: (Check one) ❑State Owned �J VILLAGE: //a(fe NEAREST1= CITY OAD <br /> ❑ Public tor2Fam. Dwelling-#of bed roomsC _ IIARGEL TAX NUMIJ-1 <br /> Ill. BUILDING USE: (If building type is public,check all that apply) y _ a a <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. gReplacement 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 /> 11Seepage Bed 21 ❑ Mound 30 El SpecityType 41 ElHolding 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. PERI.RATE 6. SYSTEM ELEV. 7. FINAL GRADE <br /> REOUIR D(sq.ft.) PROPO ED(sq.ft.) (Gals/day/sq.ft.) (Min./inch) LEVATION <br /> ' 9 Feet 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 structed <br /> Septic Tankor Holdin Tank <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 Stamps) MP/MPRSW No.: Business Phone Number: <br /> Plumber's Atltlr as(Street,City,State,Zip Code): <br /> o. r X23 <br /> IX, COUNTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved Tsanitary Permit Fee(Includes Groundwater [Date IssuedIs in Agent Sign a(No Stamps) <br /> Approvetl ❑ Owner Given Initial <br /> l 06. <br /> Co surcharge Feel _a�7 <br /> Adverse D termination <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: IV <br /> SBD-6398(formerly Plb-67)F.11/88) DISTRIBUTION: Original to County,One Copy To:Safety8 Buildings Division,Owner,Plumber <br />