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��ILHR SANITARY PERMIT APPLICATION <br /> In accord with ILHR 83.05,Wis.Adm.Code COUNTY <br /> � �• STA ANITARY PERMIT# -)'n S <br /> –Attach complete plans(to the county copy only)for the system,on paper not less than C I LISA <br /> 8'h x 11 inches in size. ❑ Check If revision to previous piicatlon <br /> –See reverse side for instructions for completing this application. STATX PLAN I.D.NUMBER <br /> I. APPLICANT INFORMATION–PLEASE PRINT ALL INFORMATION. �5 C)— Z G <br /> PROP RTY WNER PROPERTY �7 <br /> 9 '/ (�'/a ',(/ t/a, S / TY-j, N, R I E(or <br /> PROPERTY WNER'S MAILING ADDRESS LOT# BLOCK# <br /> CIN, T TE ZIP C PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER <br /> IT k [�I <br /> IL TYPE OF BUILDING: (Check one) ❑State Owned � VILLAGE: NE0 CITY EST o <br /> ❑ Public 1 or 2 Fam. Dwelling,#of bedrooms R k9wN W, <br /> CEL TAX NUMBER(b) <br /> 111. 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 ❑ 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 ❑ 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.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) ELEVATION <br /> (�!'G�(,./ Feet Feet <br /> VII. TANK CAPACITY Site <br /> in allona Total #of Prefab. Fiber- Exper. <br /> INFORMATION New istin Gallons Tanks Manufacturer's Name oncrete Con- Steel glass Plastic App <br /> Tanks Tanks strutted <br /> Septic Tank or HoldingTank I <br /> Lift Pum Tank/SI hon Chamber <br /> Vlll. 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: o Stamps) MP/MPRSW No.: Business Phone Number: <br /> Plumber's Address(Street,City,State,Zi Co ): <br /> � 1 <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> Disapproved I Sanitary Permit Fee(includes Groundwater Date Issued Iss Ing gent Sign (No Stamps) <br /> Approved ❑ Owner Given Initial �fJ Surcharge Fee) <br /> AdverseDetermination0— 5���—qa <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(formerly Plb67)(R.11/89) DISTRIBUTION: Original to County,One Copy To:Safety&Buildings Division,Owner,Plumber <br />