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DILHR SANITARY PERMIT APPLICATION �O <br /> _��•��� In accord with ILHR 83.05,Wis.Adm.Code <br /> STATESANITAR PERMIT#oZg30� <br /> -Attach complete plans(to the ounty copy only)for the system,on paper not less than ❑ J'Jr3 <br /> 8'%x 11 inches in size. elk If revs to previous application <br /> -See reverse side for instructions for completing this application. STATE PLAN I.D.NUMBER <br /> 1. APPLICANT INFORMATION PLEASE PRINT ALL INFORMATION. <br /> PROPERTY OWNER PROPERTY LOCATION <br /> f% (l E'Yt c Y4,S i l T -69, N, R <br /> PROPERTY OWNER'S MAILING ADDRESS LOT# —?#*T 04 131.L.. I BLOCK# <br /> 076 5a S W. L�Psemk t cwi, - <br /> CITY,STATEZ ODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER <br /> e�or.2JJ ...J. `}$D I 635-2q s <br /> CITY NEAREST ROAD <br /> IL TYPE OF BUILDING: (Chet one) <br /> ❑ State Owned ❑ VILLAGE IZ-.SK 7 eY r LAtnf <br /> 10 IRM OF' <br /> ❑ Public 91 or 2 Fa Ti.Dwelling-#of bedrooms z PARCEL TAX Nu ERO ,_ <br /> Ill. BUILDING USE: (If building type is public,check all that apply) a Z/I i_ 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 Bit 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: (Chet only one) <br /> Non-Pressurized Distribution Pressurized Distribution Experimental Other <br /> 11 ® Seepage Bed 21 ❑ 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. ABSORPTION SYSTEM INFORMATION: <br /> 1.GALLONS PER DAY 2.ABS RP.AREA 3.ABSORP.AREA 4. LOADING RATE 5. PERC.RATE 6. SYSTEM ELEV. 7. FINAL GRADE <br /> REOUI ED(sq.ft.) PROPOSED(sq.ft.) (Gals/day/sq.ft.) (Min./inch) ELEVATION <br /> ..300 9 "2 , ti A �'-�. ) Feet q6• I Feet <br /> VII. TANK A'PACITY Site <br /> n allons Total #of Prefab. Fiber- Exper. <br /> INFORMATION N w istin Gallons Tanks Manufacturer's Name oncret Con- Steel glace Plastic App <br /> - <br /> VII. <br /> nks Tanks <br /> structed <br /> Septic Tank 00 <br /> Lift Pump Tank/Siphon Chamber <br /> VIII. RESPONSIBILITY STATEMENT <br /> I,the undersigned,assume responsibility for installation of Up onsite sewage system shown on the attached plans. <br /> Plumber's Name(Print): umber' Signature:( o stamps) IJ�/MPRSW No.: Business Phone Number: <br /> 3353 -7 635 7`F�Z <br /> �. �.er �-srrv� \\ p <br /> Plum is Ad5G St�XCity,I'Z Zi;Code):CA m0 rl-C- -It) - <br /> IX., <br /> - <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> Disapproved Sanitary Permit Fee(Includes Groundwater a e Saul Issuin gent signature(No Stamps) <br /> _ rcharge Fee) ' <br /> Approved ❑ Owner Given I ilial I�� /�,�-(� ' J�'L� <br /> Adv Deter (nation ' <br /> X. CONDITIONS OF APPROVALIREASONS FOR DISAPPROVAL: <br /> SBD-6398(formerly Plb-67)(R.11/88) DISTRIBUTION: Original to County,One Copy To:Safety&Buildings Division,Owner,Plumber <br />