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��ILHR SANITARY PERMIT APPLICATION <br /> In accord with ILHR 83.05,Wis.Adm. Code courlTv <br /> — v r <br /> STAT SANITAR RMIT Jy�;may.+ <br /> –Attach complete plans(to the county copy only)for the system,on paper not less than ❑�f(��a / <br /> 6'//i x 11 IrICheS In SIZe. eck if revieio o previous application <br /> -See r@V@fSe SIdB for IRStrUCtIORS for COmpleting th 13 BppliCation. STATE PLAN I.D.NUMBER <br /> I. APPLICANT INFORMATION–PLEASE PRINT ALL INFORMATION. .��p�– <br /> PROPERTYOWNER PROrPERTY LOCATION <br /> C '/a '/a, S T � QN, R E (or W <br /> PROPERTY OWNER'S MAILING ADDRESS LOT# SCK'#' <br /> G l,� l� - <br /> C TY.STATE ZIP CODE PHONE NUMBER <br /> ry � f � o� P ZO <br /> II. TYPE OF BUI DING: Check one CITY � NEAREST ROAD p <br /> ( ) ❑State Owned VILLAGE CJ` i �/! (� LK - R <br /> ❑ Public 1or2Fam. Dwelling—#ofbedrooms3 A AX NUM ( ) R <br /> III. BUILDING USE: (If building type is public,check all that apply) ��— T I O�— �b—�Q� <br /> 1 ❑ ApUCondo <br /> 2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility <br /> 3 ❑ Campground 7 ❑ Merchandise: Sales/Repairs 11 ❑ RestauranUBar/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. TYt PSE OF PERMIT: (Check only one in line A. Check line B if applicable) <br /> A) 1. L2SI 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.) PROP/O-SED(sq.ft.) (Gals/day/sq.ft.) (Min./inch) q/ (,, ELEVATION <br /> ("�' �� (�Z. S S� • � l b � `�' 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 do <br /> Litt Pum TanWSi 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:(No S ps) MP/MPRSW No.: Business Phone Number: <br /> �c� o ►z s 3 z� 7i� $G6- l <br /> lumber's Add�re"ss(Street,City,State,Zip Code): ��'�7 <br /> �� �10� hl � �J I-C--J� ) 1 <br /> IX. OUNTY/DEPARTME T USE ONLY <br /> ❑ Disapproved Sanita Permit Fee(Includes Grountlwater ae ss IssuingA en gn e(No ps) <br /> lo�/urge Fee) <br /> pproved ❑ Owner Given Initial <br /> A v Determin tin f� <br /> X. CONDITIONS OF APPROVAUREASONS FOR DISAPPROVAL: <br /> SBD�fi398(formerly Plb�7)(R.11/88) DISTRIBUTION: Original to County,One Copy To:Safery&Buildings Division,Owner,Plumber <br />