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�DILHR SANITARY PERMIT APPLICATION <br /> In accord with ILHR 83.05,Wis.Adm.Code couNTv <br /> STATE AANITARYPERMIT#, <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than ❑ l/ 171.hO <br /> 8'%x 11 inches In size. Check If rev on 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 /> R '/4 ''/4, S- T , N, R S E(D <br /> PROPERTY ER'S MAILING ADDRESS LOT# BLOCK# <br /> t> AV. S:i: I <br /> CITY,STATE ZIP CODE PHONE NUMBER SUBDIVISIO NAME OR CSM NUMBER <br /> If. TYPE OF BUILDING: (Check one) ❑State Owned VILLAGITY AE N OA /f <br /> ❑ Public [A1 or 2 Fam.Dwelling-#of bedrooms �C <br /> III. BUILDING USE: (If building type is public,check all that apply) H— <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. KNew 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 21ZMound 30 ❑ Specify Type 41 ❑ Holding Tank <br /> 12 El 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 13.ABSORP.AREA 14. LOADING RATE 15. PERC.RATE 6. SYSTEM ELEV. 7. FINAL GRADE <br /> 2 REQUIRED(sq.ft.) PROPOSED(sq.ft.) (Gals/day/sq.ft.) (Min./inch) ELEVATION <br /> Jp'� 75K� .5 99, 1 Feet D - � <br /> VII. TANK CAPACITY Site <br /> in oallons Total #of Prefab. Fiber- Exper. <br /> INFORMATION New istin Gallons Tanks Manufacturer's Name oncret Con- Steel glace Plastic App <br /> Tanks I Tanks structed <br /> Se tic Tank or Holdina Tank <br /> Lift Pump Tank/SI hon Chamber <br /> Vlll. RESPONSIBILITY STATEMENT <br /> 1,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 mps) MP/MPRSW No.: Business Phone Number: <br /> c n rr5 3 l S S <br /> lumber's Address(Street,city,State,Zip ): '•'1 <br /> 7_ W <br /> IX. COUNTY/DEPARTMENT USE ONkA <br /> Disapproved Sanitary Permit Fee(Includes Groundwater a ssu Imu' g gent SI re(No Stamps) <br /> Approved ❑ Owner Given Initial �r�, �/��v-�.--��Surcharge Fee) <br /> Adv r rmin tion ok.N W <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-8398(formerly Plb-67)(R.11/88) DISTRIBUTION: Original to County,One Copy To:Safety 8 Buildings Division,Owner,Plumber <br />