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�DILHR SANITARY PERMIT APPLICATION <br /> In accord with ILHR 83.05,Wis.Adm.Code COUNTY 7 <br /> �• _� STATESNERMIT#''l �� <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than C JOI �C <br /> 8'%x 11 inches in size. ❑ Check It revisi n 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 /> PROP OWNER PROPERTY LOCATION ��j <br /> '/a '%.S T y{ /, N, R E(or <br /> PRO)k T MAILIN ADDRESS LOT# 13 <br /> CITY, �STA T E s ZIP CODE PHONE NUMBE SUBDIVISION NAME OR CSM NUMBER�w <br /> /IIA/ 5' 13 -G/ <br /> II. TYPE OF BUILDING: (Check one) CITY NEAREST ROAD <br /> State Owned VILLAGE <br /> NU OF <br /> 1 or 2 Fam. Dwelling,#of bedrooms PARCEL Ax u ( ) <br /> El Public <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. A 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 51 2.ABSORP.AREA 3.ABSORP.AREA 4. LOADING RATE 5. PERC.RATE 6. SYSTEM ELEV. 7. FINAL GRADE <br /> REQUIRED(sq.ft.) PROPOS D(s .ft.) (Gals/d�a7y/sq.ft.) (Min./in h) n VATION <br /> / 1 /� -/ Feet 3 Feet <br /> CAPACITY <br /> VII. TANK Site <br /> in gal Total #of Prefab. Fiber- Expp. <br /> INFORMATION New istin Gallons Tanks Manufacturer's Name cncret Con- Steel glass Plastic App <br /> Tanks Tanks strutted <br /> Septic Tank or Holding Tank -- y✓ <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 Name(Print): Plumber's Signature:(No S pa) MP/MPRSW No.: Business Phone Number: <br /> � <br /> Q /m .�� <br /> Plumber's Address(Street,City,State Zi Cocte): <br /> U. K 3 k_7;7sf , .c/l g 3 <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> t`pr1 ❑ Disapproved Sanitary Permit Fee(Includes Groundwater a e ss a Is sui gent SI tura(No Stamps) <br /> Ipl Approved ❑ Owner Given Initial 10 - / <br /> surcharge Feel / <br /> 1 \ <br /> Ad v Determination S.vv <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-M8(formerly Plb-67)(R.11/88) DISTRIBUTION: Original to County,One Copy To:Safety&Buildings Division,Owner,Plumber <br />