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SANITARY PERMIT APPLICATION <br /> In accord with ILHR 83.05,Wis.Adm.Code couNTr <br /> DILHR _-17_ <br /> STATE ANITA PERMIT#�C�3 <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than 05-16j <br /> 8%x 11 inches in size. ❑ Check If revis' n 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 /> PRFTY OWNER P OPERTV LOCATION <br /> �, Rk j (1 '/4 '/4,S 2b T C, N, R E (or) W <br /> PROP RTY WNER'S MAILING ADDRESS LOT# BLOCK# <br /> CITY,STATE ( ZIP CODE PHONE NUMBER_ SUBDIVISIO NAME OR CSM NUMBER /O <br /> 74 <br /> Li ITY <br /> 11. TYPE OF BUILDING: (Check one) ❑ State Owned VILLAGE: NEAREST ROAD <br /> �p�if (D <br /> ❑ Public 1 or 2 Fam. Dwelling-#of bedrooms A NUIVItStMIS1 <br /> III. BUILDING USE: (If building type is public,check all that apply) "fin_ �/ �D '"� _7; ?1 <br /> 1 ❑ Apt/Condo c�)O JS Q <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 Bit 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-Pressurized Distribution Pressurized Distribution Experimental Other <br /> 11Seepage Bed 21 ElMound 30 EJ SpecifyType 41 ElHolding Tank <br /> 12 K 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.) PROPOSED(sq.tt.) (Gals/day/sq.ft.) (Min./inch)-72— 121 _ ELEVATION <br /> S . Feet Cj n Feet <br /> VII. TANK CAPACITY Site <br /> in alit a Total #of Prefab. Fiber- Exper. <br /> INFORMATION New istin Gallons Tanks Manufacturer's Name oncrete Con- Steel glass Plastic App <br /> Tanks Tanks strutted <br /> Septic Tank or Holding Tank O <br /> Lift Pu mp Tank/Si phon 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 Si nature:(No Stamps) MP/MPRSW No.: Business Phone Number: <br /> _ o ( <br /> Plumber's Address(Street,City,State,Zip Good): <br /> 'D16 " 35 IP- cp— 1 �� <br /> IX. COUNTYIDEPARTMENT USE ONLY <br /> Disapproved Sa tary Permit Fee(Includes Groundwater Datelssue Issui ant Signa (No Stamps) <br /> Approved ❑ Owner Given Initial IoS /-�-�Surcharge Fee) <br /> Adverse Determination <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> L <br /> SBD-6398(formerly Plb-67)(R.11/88) DISTRIBUTION: Original to County,One Copy To:Safety&Buildings Division,Owner,Plumber <br />