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�ILHR SANITARY PERMIT APPLICATION COUNTY <br /> In accord with ILHR 83.05,Wis.Adm.Code <br /> STATESS'ANITARRY/ RMIT# <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than ❑ c! previous application <br /> 8%x 11 inches in size. het <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 /> 6TE12 �llS S Z9 T N. R �to E (Gr W <br /> PROPERTY OWNER'S MAILING ADDRESS LOT# BLOCK# <br /> CITY,STATVE (� ZIP CODE PHONE NUMBER SUBDaV nh."+N.` <br /> �` ,. NEAREST ROAD <br /> it. TYPE OFUILD(IINNG: (Check one) [_1 State Owned VILLAGE:5� 15 s <br /> 05 <br /> ❑ Public LSI 1 or 2 Fam. Dwelling-#of bedrooms I AR LAX UM ER ) <br /> III. BUILDING USE: (If building type is public,check all that apply) 3a-.63 a9 GL-�-CM <br /> 1 ❑ APVCondo <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.,1�.Replacement 3. ❑ Replacement of 4. ❑ Reconnection tingSystem 5.❑ Repair of an Existing System <br /> System System Tank Only 9 <br /> B) ❑ A Sanitary Permit was previously issued. Permit# — <br /> Date Issued <br /> V. TYPE OF SYSTEM: (Check only one) <br /> Non-PP((( 42 ❑ Pit Privy Distribution Pressurized Distribution Experimental Other El Seepage Bed 21 ❑ Mound 30 SpecityType 41 El Holding Tank <br /> 12 Seepage Trench 22 ❑ In-Ground 43 El Vault Privy <br /> 13 ❑ Seepage Pit Pressure <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 ELEVATION GRADE <br /> REO IyQED(sq.ft.) PR(O_POSED(sq.ft.) (Gals/day/sq.tt.) (Min./inch) i <br /> S o o OD (DO O • S S 1 Of .0 Feet ® -b Feet <br /> VII. TANK CAPACITY Site Fiber- Exper. <br /> in allons Total #of Prefab. <br /> INFORMATION New istin Gallons Tanks Manufacturer's Name oncret Con- Steel glass Plastic App <br /> strutted <br /> Tanks Kanks <br /> Septic Tank or Holdino Tank <br /> Lift Pump Tank/Siphon 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 Signature: No Stam ) MP/MPRSW No.: Business Phone Number: <br /> Plumber's Name(Pring: g ( `. <br /> O l tj IQb <br /> PI tuber's Addresa�treel,City,StateM,Z1ip Cod� Wgq <br /> IX. COUNTY/DEPARTMENT USE ONLY / Issuing A nt Si nature o tamps) <br /> Ej Disapproved Sanitary Permit Fee(IaurchargerFee)water ate u <br /> Approved ❑ Owner Given Initial a� <br /> Advem termin I n —tom �J <br /> X. CONDITIONS OF APPROVALIREASONS FOR DISAPPROVAL: <br /> SBD-13398(formerly Plb.87)(R.11/88) DISTRIBUTION: Original to County,One Copy To:Safety&Buildings Division,Owner,Plumber <br />