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DILHR SANITARY PERMIT APPLICATION <br /> In accord with ILHR 83.05,Wis.Adm.Code couNTv <br /> • �� STAT`0$ I][JTAfi�(PERMIT# -S <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than 11bsf\/ <br /> 8'%x 11 inches in size. ❑ Check if revi on 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 /> PROPERTY OWNER PROPERTY LOCATION <br /> cb este 56, t n%AJ a *w %, S 4 T 35', N, R 1y- �)W <br /> PROP OWNER'S MAILING MESS LOT# BLOCK# <br /> o O 4} w <br /> CITY,STAT E1 ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER <br /> tA-tP�bNW LAY, <br /> II. TYPE OF BUILDING: (Check one) El State Owned ❑13 <br /> viLUGE NEAREST ROAD <br /> H <br /> El Public ®1 or 2 Fam. Dwelling,#of bedrooms?- AXNUMBER(K) <br /> III. BUILDING USE: (If building type is public,check all that apply) �A•—3\bq_ G <br /> 1 ❑ Apt/Condo <br /> 2 ❑ Assembly Hall 6 ElMedical 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 ❑ 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 7 2.ABSORP.AREA 13.ABSORP.AREA 14. LOADING RATE 15. PERC.RATE 16. SYSTEM ELEV. 17. N <br /> AL GRADE <br /> REQUIRED(sq.ft.) PROPOSED(sq.ft.) (Gals/day/sq.ft.) (Min./inch) ELEVATION <br /> 300 410 r -7 < 3 1 9+Z Feet 9 1p.Z Feet <br /> CAPACITY <br /> VII. TANK Site <br /> in Gallons Total #of Prefab. Fiber- Exper. <br /> INFORMATION New istin Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App <br /> Tanks 1Tanks structed <br /> Septic Tank or Holding Tank D( 750 I Lk), e-V Is <br /> Litt Pum Tank/Si hon Chamber <br /> VIII. RESPONSIBILITY STATEMENT <br /> 1,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 ps) MP/MPRSW No.: Business Phone Number: <br /> e. n �rar kso�t _a IZ 3353 7ij 63 S-7SS <br /> 9 <br /> Plum er's Address(Street, ,State,Zip Code): .1 <br /> O, ✓ ImoST <br /> UX —I , Cavie , ) <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> Disapproved Sanitary Permit Fee(Includes Groundwater Date Issued Issu' g Agent Si nature(No Stamps) <br /> roved Surcharge Fee) <br /> p ❑ Owner Given Initial \ .1�C caro <br /> Adverse Determination J u 1. <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-M8(formerly Plb-67)(R.11/88) DISTRIBUTION: Original to County,One Copy To:Safety&Buildings Division,Owner,Plumber <br />