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DILHR SANITARY PERMIT APPLICATION COUNTY <br /> In accord with ILHR 83.05,Wis. Adm. Code krn <br /> MINNOW STATE$I�NITiA,R!ERMiT#093x73 <br /> —Attach complete plans(to the county copy only)for the system,on paper not less than CC II!l�177 // <br /> 8'%x 11 inches in size. ❑ Check if revis on to previous application <br /> —See reverse side for instructions for completing this application. STATE tPAnl-�o BERER <br /> I. APPLICANT INFORMATION—PLEASE PRINT ALL INFORMATION. "I J / <br /> PROPERTY OWNER PROPERTY LOCATION <br /> 1__A0av1n R �V tj al %St.J%, S -LO T L+O, N, R I <br /> PROPERTY OWNER'S MAILING ADDRESS LOT# BLOCk�f <br /> �/ '4 <br /> CITY,STATE ZIP CODE7 PI HONE NUMBER SUBDIVISION NAME OR CSM NUM e R - I <br /> ,r,� Mn <br /> kl <br /> 5503 / <br /> Li CITY NEAR ST ROAD <br /> II. TYPE OF BUILDING: (Check one) ❑ State OwnedVILLAGE ��-Vt 0,}K L/9K£ R� <br /> ❑ Public ®1 or 2 Fam. Dwelling--#of bedrooms Z PA EL TA Nu )5R( ) <br /> 111. BUILDING USE: (If building type is public,check all that apply) ice— I I�0— <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. ® New 2. ❑ Replacement 3. El Replacement of 4. ❑ Reconnection of 5.El 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 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 DAY 2.ABSORP.AREA 13.ABSCIRRAREA 14. LOADINGIRATE 5. PERC.RATE6. SYSTEM ELEV. 17. FINAL GRADE <br /> REQUIRED(sq.ft.) PROPOSED(sq.ft.) (Gals/day/sq.ft.) (Min./inch) ELEVATION <br /> Feet Feet <br /> VII. TANK CAPACITY Site <br /> in allons Total #of Prefab. Fiber- per. <br /> INFORMATION Naw istin Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App <br /> Tanks Tanks strutted <br /> Septic Tank orHoldin Tank ODO A oao / r45a-✓5 <br /> Litt Pum Tank/Siphon Chamber <br /> VIII. RESPONSIBILITY STATEMENT <br /> I,the undersigned,assume responsibility for installation of the ons'a sewage system shown on the attached plans. <br /> Plumber's Name(Print): I ber'a Signature:(No S ps) MP/MPRSW No.: Business Phone Number: <br /> utrtS 3393 715' -7 5'5',5- <br /> Plumber's Address(Street,6W,State,Zip Code): <br /> • D, 7I 00 L ) , <4 DI <br /> IX COUNTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved Sa ttary Permit Fee(Includes Groundwater a e IssuedIssuing Apent Signature(No Stamps) <br /> �.I, Surcharge Fse) r, a <br /> Approved ❑ Owner Given Initial �. GXJ <br /> Adverse Determination ���III--111 U l.�All <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&Buildings Division,Owner,Plumber <br />