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�ILHR SANITARY PERMIT APPLICATION COUNTY In accord with ILHR 83.05,Wis.Adm.Code <br /> STATE SANITARY RMIT# <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than (15a <br /> 814 x 11 inches in size. ❑ Check If revislo to previous application <br /> -See reverse Side for Instructions for Completing this application. STATE PLAN I.D.NUMBER <br /> 1. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION. <br /> PRO TY O NER PR PERTY LOCATION ��} <br /> '/ 1/4, T", N, R E (o W <br /> PROPERTY OW E 'S M ILING ADDRESS <br /> CI ,STA /' ZIP C�E PHONE NUM ER - SUBDIVISION NAME OR OSM NUMBER <br /> If. TYPE OF BUILDICNrji/L: (Check one) ❑State Owned Li VIL�LAOE / NEA EST R D �,/ <br /> ❑ Public 1 or 2 Fam.Dwelling-#of bedrooms Ct J � zwb-l`J ,C�{ <br /> III. 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 inline 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-yyyP(((ressurized 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 72.ABSORP.AREA 3.ABSORP.AREA 4. LOADING RATE 5. PERC.RATE 6. SYSTEM ELEV. 7. FINAL GRADE <br /> 269REOUIR D(sl ft.) PROPt5 Laq.ft.) (Gala/day/sq.ft.) (Min./in ) �� ELEVATION <br /> Q Feet 6!(, Feet <br /> VII. TANK CAPACITY Site <br /> in gallons Total #of Manufacturer's Name Prefab. Con- Steel Fiber- plastic Exper. <br /> INFORMATION New Istin Gallons Tanks oncrete glass App. <br /> Tanks I Tanks structed <br /> Septic Tank or Holding Tank <br /> Lift Pump Tank/Siphon Chamber <br /> Vlll. 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 Ste s) MP/MPRSW No.: Business Phone Number: <br /> lum r' Add re (St L City,State,Zip Co <br /> IX./COUNTY/DEPARTMENT USE ONLY 1 <br /> Ej Disapproved I flianitary Permit Fee(includes Groundwater Date isaue I I A7gent (No Stamps) <br /> Approved ❑ Owner Given Initialci Suroherge Fee) <br /> Adyeris Determination <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&Buildings Division,Owner,Plumber <br />