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DILHR SANITARY PERMIT APPLICATION <br /> In accord with ILHR 83.05,Wis.Adm.Code COUNTY <br /> STATE TE/SANII-TAR'Yy RMIT#13n 31� <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than ❑ R 1510S / <br /> 8'b x 11 inches in size. c eck If revlsio 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 / s PROPERTY LOCATION �j <br /> /U-e, Fro d eal t1keps rand /(,WY.VE %,S `7 T4W <br /> 0, N, R � E (or <br /> PROPERTY OWNER'S MAILING ADDRESS LOT# BLOCK# <br /> Oo row+mer K -e N <br /> CITY,STAT 4 ZIP CODE PHONE NUMBER SUB 1 N ME OR CSM NUMBrER <br /> 22 <br /> II. TYPE OF BUILDING: Check one CITY O 4 t NEAREST RQAD <br /> ( ) State Owned VILLAGE �Fn <br /> l�amy, /'QI'Q c.A <br /> ❑ Public L.C71 or 2 Fam. Dwelling-#of bedrooms S�L. A UM E ( ) <br /> 111. BUILDING USE: (If building type is public,check all that apply) �O_'I-�SO_ O "l_Loo 1 ElApt/Condo 'I D oS �f <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. TYPPEt;OF PERMIT: (Check only one in line A. Check line B if applicable) <br /> A) 1. Y 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 ❑ 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 F7 2.ABSORP.AREA 3.ABSORP.AREA 4. LOADING RATE 15. PERC. RATE 6. SYSTEM ELEV. 7. FINAL GRADE <br /> REQUIRED(sq.ft.) PROPOSED(sq.ft.) (Gals/day/sq.ft.) (Min./inch) EVA ION <br /> 3 Q q 3 )L- • (a r '3-.Feet �'�Feet <br /> CAPACITY <br /> VII. TANK in al Ions Total Site <br /> INFORMATION #of Prefab. Fiber- Exper. <br /> New xistin Gallons Tanks Manufacturer's Name oncret Con- Steel glass Plastic App <br /> Tanks Tanks strutted <br /> Septic Tank or Holdino Tank <br /> Lift Pump 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): Plu er's Signature:(No Stamps) MP/MPRSW No.: Business Phone Number: <br /> o ;� c s 0 3 o s 74 Pte'- 0' - <br /> Plumber' Address( tre t,City,State,Zip Code): p <br /> L-4' z 0 <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved Sanitary Permit Fee(Includes Groundwater a e ssue Iss ' g gent Signat o Stamps) <br /> Approved ❑ Owner Given Initial I�SSurcharge Feel n ^_ <br /> Adverse in n <br /> X. CONDITIONS OF APPROVAUREASONS FOR DISAPPROVAL: <br /> SBD-6398(formerly Plb-67)(R.11/88) DISTRIBUTION: Original to County,One Copy To:Safety B Buildings Division,Owner,Plumber <br />