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�ILHR SANITARY PERMIT APPLICATION <br /> In accord with ILHR 83.05,Wis.Adm. Code COUNTYp <br /> STATESA ITA YPER 11,T#ia�3S <br /> —Attach complete plans(to the county copy only)for the system,on paper not less than �C� 1 <br /> 8'r4 x 11 inches in size. ❑ Chec if revision to evioua application <br /> wee reverse SIdB for IDSIrUCtIOnS for Completing this application. STATE PLAN I.D.NUMBER <br /> I. APPLICANT INFORMATION—PLEASE PRINT ALL INFORMATION. <br /> PROPERTY OWNER PROPERTY LOCATION <br /> _.)Q g2 ) a '/a )E '/a, S q TN, R , E(or) <br /> PROPERTY OWNER'S MAILING ADDRESS LOT# BLOCK# <br /> CITY,STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER <br /> t. _ ( [ — � V, <br /> II. TYPE OF BUILDING: (Check one CITY NEAREST ROAD <br /> State Owned 3 ❑ VILLAGE'tr4C <br /> ❑ Public 1 or 2 Fam. Dwellingof bedrooms DAKE F0 <br /> L Ax NUMBER( ) <br /> Ill. BUILDING USE: (If building type is public,check all that apply) % _ a©�— V3— �•^�� <br /> 1 ❑ Apt/Condo 7 HCl <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. TYPEI OF PERMIT: (Check only one in line A. Check line B if applicable) <br /> A) 1. lY� 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 /> 11Seepage Bed 21 ElMound 30 ❑ Specify Type 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 [y X 36 <br /> VI. ABSORPTION SYSTEM INFORMATION: 5 <br /> 1.GALLONS PER DAY 2.ABSORP.AREA 3.gle— <br /> RP.ARE 4. LOADING RATE 5. PERC.RATE 6. SYSTEM ELEV. 7. FINAL GRADE <br /> REQUIRED(sq.ft.) PED R. <br /> ft.) (Gals/day/sq.ft.) (Kin./inch) ELEVATION <br /> _ 1(� G—Feet `> 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 Holdin Tank <br /> Lift Pum Tank/ i hon 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:(N Stamps) MP/MPRSW No.: Business Phone Number: <br /> IRAb? S c <br /> Plumber's Address(Street,City,State,Zip e): <br /> 2WI S'Q <br /> IX COUNTY/DEPARTM NT USE ONLY <br /> Disapproved Sanitary Permit Fee(Includes Groundwater a e IssuedIs n Agent Sig lure(No Stamps) <br /> Approved ❑ Owner Given Initial '..surcharge Fee) C. <br /> Adverse D termin tin ' ' <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(formerly Plb-67)(R.11/89) DISTRIBUTION: Original to County,One Copy To:Safety 8 Buildings Division,Owner,Plumber <br />