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DILHR SANITARY PERMIT APPLICATION <br /> couNTv r <br /> In accord with ILHR 83.05,Wis.Adm.Code <br /> �M�• - STAT ANITAR ERMIT# �55 <br /> —Attach complete plans(to the county copy only)for the system,on paper not less than C 17075) <br /> 8'%x 11 inches in size. 11Checkif rev! n 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 PSUBDIVISION <br /> ATION <br /> F E '/a, S �� T 0, N, R j� E(or W <br /> PROPERTY OWNER'S MAILING A KESS BLOCK# <br /> 30 6 W PV. <br /> STATE ZIP CODE PHONE NUMBER AME OR CSM NUMBER <br /> II. TYPE OF BUILDING: (Check one) NEAREST ROAD <br /> j ❑State OwnedOAK �Q❑ Public ! 41 or 2 Fam. Dwelling-#of bedrooms 2UMIII. BUILDINGUSE: (If building type is public,check all that appl — — Q)-�j�� <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. ❑ 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 Seepage 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 PE2.ABSORP.AREA 3.ABSORP.AREA 4. LOADING RATE 5. PERC.RATE 6. SYSTEM ELEV. 7. FINAL GRADE <br /> REQUIRED(sq.ft.) PROPOSED(sq.ft.) (Gals/day/sq.ft.) (Min./inch) 6 i ELEVATION <br /> 300R DAY 114 0 yso �L . 3 1 Feet IC� .� Feet <br /> CAPACITY <br /> VII. TANK Site <br /> ingallons Total #of Prefab. Fiber- Expp. <br /> INFORMATION New istin Gallons Tanks Manufacturer's Name oncrete Con- Steel glass Plastic App <br /> Tanks I Tanks strutted <br /> Septic Tank or Holdin Tank <br /> Lift Pum 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 /> Plumber's Name(Print): Plumber's Signature:(NO S)pmps) MP/MPRSW No.: Business Phone Number: <br /> (I-OA Qe ( Its <br /> Plumber's Address(Street,City,State,Zip Code): <br /> 2,7 ,7&0 3S t.,l63sfc2 (,J1 . 3`1893 <br /> IX. COUNTY/DEPARTMENT US ONLY <br /> ❑ Disapproved Sanitary Permit Fee(In Ircdha gGroun water Date IssuedIssuing a igna N temps) <br /> pproved Ed Owner Given Initial b}" (��. /.� <br /> Adverse Determination .Swb lilt <br /> X. CO ITIONS 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 />