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DILHR SANITARY PERMIT APPLICATION <br /> In accord with ILHR 83.05,Wis.Adm.Code COUNTY <br /> STATE SANITARY RqRMIT#)(IS309 <br /> —Attach complete plans(to the county copy only)for the system,on paper not less than Ira <br /> 81/2x 11 inches In size. Elcheckchlf revisiont 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 PROPERTY L ATION <br /> 0 CQTT F. V Rf J SR • S '/4� %,S I T3 , N, R 19 E(or W <br /> PROPERTY OWNER'S MAILING ADDRE LOT# BLOCK# <br /> 3235 - Nil <br /> CITY,STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER <br /> _SVAFLL L.A KE W 1 . S'j of Z 12, l <br /> If. TYPE OF BUILDING: (Check one) ❑State Owned CILTY NE REST ROAD <br /> ❑ Public A1 or 2 Fam. Dwelling-#of bedrooms— IRITWER0MB <br /> 111. BUILDING USE: (If building type is public,check all that apply) Q3- <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.X 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 EJSpecify 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 DAY 2SORP.AREA 3.ABSORP.AREA 14. LOADING RATE 5. PERC.RATE 6. SYSTEM ELEV. 7. FINAL GRADE <br /> REQUIRED(sq.ft.) PROPOSED(sq.ft.) (Gals/day/sq.ft.) (Min./inch) ELEVATION <br /> Soo 4000 $6 4(p 1 3 q4, 3 Feet Feet <br /> CAPACITY <br /> VII. TANK Site <br /> in alit s Total #of Prefab. Fiber- Exper. <br /> INFORMATION New istin Gallons Tanks Manufacturer's Name oncret Con- Steel glass Plastic App <br /> Tanks Tanks strutted <br /> Se tic Tank or Holdin 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): Plumber's Signature:(No Stamps) MP/MPRSW No.: Business Phone Number: <br /> )cNA20 NoPK)NSfall" 3 2� IS <br /> Plumber's Address(Street,City,State,Zip Codd): <br /> 277GO H w 35 WEesTER W 1 - 4199-5 <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> Disapproved SanitaryPermit Fee(Includee Groundwater aessue Issuing Ag tSi ature( Stamps) <br /> Surcharge Fee) //f _ <br /> pproved ❑ Owner Given Initial //�� <br /> Adverse D rmin i n /0 <br /> X. CONDITIONS OF APPROVALIREASONS FOR DISAPPROVAL: <br /> SBD-6398(formerly Plb-67)(R.11198) DISTRIBUTION: Original to County,One Copy To:Safety&Buildings Division,Owner,Plumber <br />