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17D-ILHR SANITARY PERMIT APPLICATION <br /> In accord with ILHR 83.05,Wis.Adm.Code COUNTY —� <br /> STATE SANITAR�PERMIT <br /> —Attach complete plans(to the county copy only)for the system,on paper not less than ❑ ��Q <br /> 8%x 11 inches in size. C eck If re 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 P OP RTYL ATION <br /> O ya /a, S T N, R � E (or W <br /> PROPERTY OWNER'S MAILIN ARESS LOT <br /> LOCK# <br /> 17, <br /> CITY,STATE ZI PON NUMBER <br /> I n?1 0 CIZ <br /> II. TYPE OF BUILDIN (Check one CITY NEAREST ROAD <br /> State Owned VILLAGE:L4 i—N Aft <br /> ❑ izn <br /> Public 1or2Fam. Dwelling,#ofbedrooms� L AXNUMBE ( C(�V <br /> III. BUILDING USE: (If building type is public,check all that apply) `i <br /> — 3 .33— 0) — C)D <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. TYP OF PERMIT: (Check only one in line A. Check line B if applicable) <br /> A) 1. New 2. El Replacement 3. ❑ Replacement of 4. El Reconnection of 5.❑ Repair of an <br /> ystem 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 /> 11Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ElHolding 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 DAY 2.ABSORP.AREA 3.ABSORP.AREA 4. LOADING RATE 5. PERC.RATE 6. SYSTEM ELEV. 7. FINAL GRADE <br /> RE UIRED(sq.ft.) PROPO ED(sq.ft.) (Gail /d ft.) (Min./'nth) ELEVATION <br /> 'L'7—lr/1 a�p Feet Feet <br /> VII. TANK CAPACITY Site <br /> in gallons Total #ofTanks <br /> Manufacturer's Name Prefab. Con- Steel Fiber- Plastic Exper. <br /> INFORMATION New istin Gallons Tanks oncret glass App. <br /> Tanks Tanks strutted <br /> Septic Tank or Holdino Tank 014 ---+ <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 /> PI u ber's Name(Print): P is Signature: No mps) MP/MPRSW No.: Business Phone Number: <br /> 112�7-6 815 - SIS <br /> lumber s Addr ss(Stre t,City,State,Zip Cod ): <br /> 2 ? w 3S �JEBSC612 11 SIS <br /> IX.,COUNTYIDEPARTME T USE ONLY <br /> Disapproved Sanitary Permit Fee(includes Groundwater ae sue Issuing Agent natu (NOS s) <br /> Approved ❑ Owner Given Initial r Surcharge Feel op <br /> AdverseDetermination '"� CC) I <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(formerly Plb-67)(R.11/88) DISTRIBUTION: Original to County,One Copy To:Safety 8 Buildings Division,Owner,Plumber <br />