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DILHR SANITARY PERMIT APPLICATION <br /> COUNTY <br /> In accord with ILHR 83.05,Wis.Adm.Code BJRt1e:TT <br /> STATES NITARYP MIT If 40 6 <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than ❑ �/C3S� <br /> 8%x 11 Inches In size. Check if revisio revious 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 /> L, '-OINNA T,YCPq I1-- '/4 � ' '/4,S 1 T 40 , N, R 15111w W <br /> PROPERTY OWNER'S MAILING ADDRESS LOT# lot 3 BLOCK# NIA <br /> Rtl BOX2_28 <br /> CITY,STATE ZIP CODE PHONE NUMBER SUBDIVISIONNAME OR CSM N MBER /�� <br /> HIIQCK Y, 1:51 55037 612— 79-521 ('Sill [ <br /> IL TYPE OF BUILDING: (Check one) 11 <br /> CITY NEAREST ROAD <br /> ❑State Owned l O VILLAGE: JACK ON LK' <br /> u6N LA .': <br /> ❑ Public 11 1 or 2 Fam. Dwelling-#of bedrooms— PARL )FUNIt1hriOnn� <br /> III. BUILDING USE: (If building type is public,check all that apply) <br /> "7 V I'— D <br /> 1 ❑ ApUCondo <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. TYPPEII OF PERMIT: (Check only one in line A. Check line B if applicable) <br /> A) 1. L.s1 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 0 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 PEF7 2.ABSORP.AREA 3.ABSORP.AREA 4. LOADING RATE 5. PERI.RATE 6. SYSTEM ELEV. 7. FINAL GRADE <br /> REQUIRED AREA <br /> ft.) PROPOSED(sq.ft.) (Gals/day/sq.ft.) (Min./inch) ELEVATION <br /> 150 205 24,6 .42 <3 93. 0 Feet 96. 0 Feet <br /> VII. TANK CAPACITY Site <br /> in alto Total #of Prefab. Fiber- Exper. <br /> INFORMATION New istin Gallons Tanks Manufacturer's Name oncret Con- Steel glass Plastic App <br /> Tanks Tanks structed <br /> Septic Tank or Holdinp Tank 7 C 1 750 1 1 1 ';,rl; -'._Tjr< <br /> Lift Pump Tank/Siphon Chamber <br /> VIII. RESPONSIBILITY STATEMENT <br /> I,the undersigned,assume responsibility for installation of onsite sewage system shown on the attached plans. <br /> Plumber's Name(Print): Plumber's SiqlratureViNo Stamps) MP/MPRSWNo.: Business Phone Number: <br /> I,:; 1, J. —�HGUS'oly I 3393 715--f35-7482 <br /> Plumber's Address(Street,City,Stale,Zip Code): <br /> HCR59 Bcx478d ,,D0c: ":R, 11 54801 <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> Fj Disapproved Sanitary Permit Fee(Includes Groundwater) Date IssuedIs in Agent Sign (No Stamps) <br /> y Surcharge Fee <br /> Approved ❑ Owner Given Initial [II I�S. f�S1 I_13_q0 <br /> Adverse D min tin lJ <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-8388(formerly Plba7)(R.11/88) DISTRIBUTION: Original to County,One Copy To:Safety&Buildings Division,Owner,Plumber <br />