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�ILHR SANITARY PERMIT APPLICATION <br /> In accord with ILHR 83.05,Wis.Adm. Code COUNTY <br /> d <br /> TATE SANITARY PERMIT#r�WR, <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than /,la�R� QW <br /> R, <br /> x 11 inches In size. ❑ C eck if revisi 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 /> PROPERTY OWNER PROPERTY LOCATION _ <br /> Ark /y Ya Irl/t, S 3J T 37, N, R MY W <br /> ROPERTY OW ER'S MAILI ADDRESS/11r,) LOT# BLOCK# <br /> 6- 1 <br /> CITY,STATE ZIPCODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER <br /> Z LLG ,Vf3 <br /> II. TYPE OF BUILDING: (Check one) El Lj CITY NEAREST ROAD <br /> State Owned ❑ VILLAGE : 750 4J3 AI7�� , 0,-e <br /> ST 8 <br /> El Public E41 or 2 Fam. Dwelling-#of bedrooms x NUMBER( ) dT �dzal <br /> III. 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. CQReplacement 3. ❑ Replacement of 4. ❑ Reconnection of 5.❑ Repair of an <br /> System System Tank Only Existing System Existing System <br /> B) X A Sanitary Permit was previously issued. Permit# 1 VI/� 130 Date Issued 7-30-75 <br /> V. TYPE OF SYSTEM: (Check only one) <br /> Non-Pressurized Distribution Pressurized Distribution Experimental Other <br /> 11Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 El Holding Tank <br /> 12 �SeepageTrench 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 /> U �9 REQUIRED(sq.ft.) PROPOSED(sq.ft.) (Gals/day/sq.tt.) (Min./inch) �j` ELEVATION <br /> , y v �J �S� / i Al 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 structed <br /> Septic Tank or Holding Tank (a raCb <br /> Lift Pum Tank/Sipon <br /> 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): PAu3bVis Signal e: No ps) MP/MPR8WNo.. Business Phone Number: <br /> /t' K <br /> Plumber' . rasa(Street,City,State,Zi Cod <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved Sanitary Permit Fee (Includes Groundwater I <br /> ae IssuedIssuing Agent Signature <br /> ✓(NI <br /> o Stamps) <br /> Approved ❑ Owner eal Suharge Fe) _�_ <br /> AdverseDetermination �InC, u�_/ <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(formerly Plb-67)F.11/88) DISTRIBUTION: Original to County,One Copy To:Safety&Buildings Division,Owner,Plumber <br />