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i SANITARY PERMIT APPLICATION <br /> 01ILHA COUNTY <br /> In accord with ILHR 83.05,Wis.Adm. Code <br /> STATE SANITARY RMIT#l��3 <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than ❑ �%/�� /7 <br /> 8%x11inchesinsize. Ch kfrevsioo previousapplication <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 /> ( Y4 ''/4, S ,W T LI , N, R (,E (or <br /> PROPERTY OWNER'S MAILING ADDRESS LOT# BLOCK# <br /> s3 [ <br /> CITY,STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER <br /> ALT A)I Mu - s� /�T >� r /� C=am. <br /> II. TYPE OF BUILDING: Check one CIN NEAREST ROAD <br /> ( ) Stat@OWned VILLAbTnwmGE:�OWN OF ,�(t7jSs �V C ��;s '2 <br /> ❑ �OWN OF <br /> Public 1 or 2 Fam. Dwelling,#of bedrooms AR LL I AX NU <br /> M <br /> 111. BUILDING USE: (If building type is public,check all that apply) <br /> 1 ❑ Apt/Condo 7 <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 �SeepageBed 21 ❑ Mound 30 L1 Specify Type 41 El 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 12.ABSORP.AREA 3.ABSORP.AREA4. LOADING RATE 5. PERC.RATE 6. SYSTEM ELEV. 7. FINAL GRADE <br /> REQUIRED sq.ft.) PROPOSED( .ft.) (Gals/day/sq.ft.) (Min./inch) G�/f ELEVATION <br /> `� 4l r 7z / / Feet /0") Feet <br /> VII. TANK CAPACITY Site <br /> in gall Total #of Prefab. Fiber- Exper. <br /> INFORMATION New fstin Gallons Tanks Manufacturer's Name oncret Con- Steel glass Plastic App <br /> Tanks Tanks at <br /> Septic Tank or Holdina Tank i• -aLl I Ll I <br /> _F 717 LI <br /> Litt Pump Tank/Si 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): Plu 's sit natur •(Non MP/MPRSW No.: Business Phone Number: <br /> Plum�lber's A ress((Street,City,State,Zip Code): <br /> �x / <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> Disapproved Sanitary Permit Fee(Includes Groundwater . a e ssu I ul Agent nature(No Stamps) <br /> Approved ❑ Owner Given Initial � / ^ V ,o,°.roharge Fee) ^� <br /> Adverse Determination <br /> �1 1.., VU x <br /> X. CONDITIONS OF APPROVALIREASONS FOR DISAPPROVAL: 41 <br /> SBD-6398(formerly Plb-67)(R.11/88) DISTRIBUTION: Original to County,One Copy To:Safety&Buildings Division,Owner,Plumber <br />