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DILHR SANITARY PERMIT APPLICATION <br /> In accord with ILHR 83.05,Wis.Adm. Code COUNTY <br /> BU r <br /> ���• � STATESANITARYY-�R�RMIT#7/j /�3/� <br /> -Attach complete plans(to he county copy only)for the system,on paper not less than ❑ �1 -7-7)77 o' {J_ 60 <br /> 8'%x 11 inches in size. eck If revisi to previous application <br /> -See reverse side for instrt ctions for completing this application. STATE PLAN I.D.NUMBER <br /> I. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION. <br /> PROPS Y OWNER PROPERTY LOCATION <br /> X\TO SCHf9 Ep, '/4 %,S23 T Q , N, R t57 E (or <br /> PROPERTYOWNER'S MAILING A DRESS LOT# BLOCK# <br /> CITY,STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER <br /> CIERLAW7 &6, 4z <br /> 11. TYPE OF BUILDING: (C eck one) ❑State Owned viLLAGE: O i E? \f4 Ay <br /> (iNb f7 <br /> ❑ Public A, or 2 Fam.Dwelling-#ofbedrooms Z 1� <br /> III. BUILDING USE: (If building type is public,check all that apply) 'a—"l J m- ( q — <br /> 1 ❑ Apt/Condo <br /> 2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility <br /> 3 ❑ Campground 7 ElMerchandise: 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: (Che k only one in line A. Check line B if applicable) <br /> IPE <br /> A) 1. LL`L 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 Permil was previously issued. Permit# — Date Issued <br /> V. TYPE OF SYSTEM: (Ch wk only one) <br /> Non-Pressurized Distrlbl.tion Pressurized Distribution Experimental Other <br /> 11 Seepage Bed 21 ❑ Mound 30 ❑ Speciy 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 PERZAj 2.A 3SORP.AREA 3.ABSORP.AREA 14. LOADING RATE 5. PERC.RATE 16. SYSTEIMELEV. T FINAL GRADE <br /> 'So c) <br /> RE U RED(sq.ft.) PROPO4%0 Lf SED 7 <br /> ED(sq.tt.) (Gals/day/sq.ft.) (Min./inch) [� E�LEVATION <br /> W lP� -15'3 Feet /• Feet <br /> VII. TANK CAPACITY Site <br /> in allona Total #of Prefab. Fiber- Exper. <br /> INFORMATION New isdn Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App <br /> Tanks Tanks strutted <br /> Septic Tank or Holdina Tank <br /> LiftPum 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): Plumber's Signature:(No mps) MP/MPRSW No.: Business Phone Number: <br /> o - 3`l is IS <br /> P umber's Address(Str f7ity, tate,Zip i), W &A 0 13 <br /> IX. COUNTY/DEPARTMEN USE ONLY O <br /> ❑ <br /> Disapprovec Sanitary Permit Fee(Includes Groundwater Date IssuedIss Agent Signature(No Stamps) <br /> L _Surcharge Fee) <br /> Approved ❑ Owner Give Initial w--� 5-��C. <br /> Adverse D rmin i n <br /> X. CONDITIONS OF APPR VAUREASONS FOR DISAPPROVAL: <br /> SBD-6398(formerly Plb-67)F.11/ ) DISTRIBUTION: Original to County,One Copy To:Safety 8 Buildings Division,Owner,Plumber <br />