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DILHR SANITARY PERMIT APPLICATION CGUNTY <br /> In accord with ILHR 83.05,Wis.Adm.Code <br /> • �� STATES/��5NNNITARYPE MIT# Its <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than l 'S5(r1 <br /> 8'%x 11 inches in size. ❑ Check if revision 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 /> PRQPERTY OWNER PROPERTY LOCATION <br /> Jt 41121 �rrL an ktc/%0/4/%, S 2? T3 , N, R E(o <br /> PROPERTY OWNER'S MAILING ADD LOT# BLO K#,{- <br /> 1 L! 1 ZZ) V ". <br /> CITY,STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER <br /> y. lM V1 BSc at/ ( e/ -6o7J cs yj Vol �Z e&,ie tzjz�hiLj <br /> II. TYPE OF BUILDING: (Check one CITY NEAREST ROAD <br /> ❑ State Owned ❑ VILLAGEpew J <br /> ❑ Public K 1 or 2 Fam.Dwelling-#of bedrooms3PARCEL TAX NUMB <br /> Ill. BUILDING USE: (If building type is public,check all that apply) <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. TYPPEF OF PERMIT: (Check only one in line A. Check line B if applicable) <br /> A) 1.J51 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 ❑ SpecifyType 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.ABSORP.AREA 14. LOADING RATE 15. PERC.RATE 16. 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 gallons 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 Q('60-1cling Tanib wieese C' <br /> Lift Pump Tank/SI hon 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): Plu bar's Si ature:( St ps) MP/MPRSW No.: Business Phone Number: <br /> WKS p c2 r � � lht PT .6 ' <br /> Plumber's Address(Street,City,State,zip Code): (r ( ` <br /> k(5- C �i2l�S � F It C 3 <br /> IX. COUNTYIDEPARTM NT USE ONLY <br /> Disapproved Sanitary Permit Fee(Includes Groundwater aessue Issuin =ntSIgnature <br /> Surcharge Fee) <br /> AP <br /> proved ❑ Owner Given Initial !�'�!" � L�—, -�I <br /> Adverse Determ'n i n <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-8398(formerly Plb-67)(R.11/88) DISTRIBUTION: Original to County,One Copy To:Safety&Buildings Division,Owner,Plumber <br />