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DIL' HR SANITARY PERMIT APPLICATION <br /> In accord with ILHR 83.05,Wis.Adm.Code COUNTY <br /> STATE S9,NRARY ERMIT# <br /> —Attach complete plans(to the county copy only)for the system,on paper not less than Il(e%klI��� /OIO /IC.IJ <br /> 8%x 11 inches in size. ❑ c frevi,fsio to 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 PROPLLOCATION <br /> �c N*�rean� 3 T 34, N, R s I wPROPERTY OWNER'S MAILING ADDRESS LOT BLOCK1-165 n bo u3 _RowD I rCITY,STATE ZIP CODE PHONE NUMBER SUBDCSM NUMBER <br /> 45900 ncI( u�; s Ol c <br /> If. TYPE OF BUILDING: (Check one) ❑State Owned 0 VILLAGE 0 CITY <br /> NEAREST ROAD <br /> Lel R syl lnbo.J <br /> ❑ Public R1 or 2 Fam. Dwelling—#of bedrooms Z PAR CEL_TAX NUM BE R( ) <br /> III. BUILDING USE: (If building type is public,check all that apply) 1 a�. 0 3. of 70 fJ <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 /> lck <br /> A) 1. FJ New 2. kn1Replacement 3. ❑ Replacementof 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 1M Seepage 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 DAY 2.ABSORP.AREA 3.ABSORP.AREA 14. LOADINGRATE 5. PERC.RATE 6. SYSTEM ELEV. 7. FINAL GRADE <br /> REQUIRED(sq.ft.) PROPOSED(sq.ft.) (Gals/day/sq.ft.) (Min./inch) V TION <br /> 300 L+2 43Z r log 3 9a•14 Feet Feet <br /> VII. TANK CAPACITY Site <br /> in allons Total #of Manufacturer's Name Prefab. Con- Steel Fiber- Plastic Exper. <br /> INFORMATION New xistiI Gallons Tanks ncret glass App. <br /> Tanks Tanks structed <br /> Septic Tank O SO t.JrGS¢✓ <br /> Lift Pump Tank/Siphon Chamber Ll 0 H El <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:( mps) kir/MPRSW No.: Business Phone Number: <br /> S 3393 �1S lo35"-Z4$7_ <br /> Plumblar's Address(Street,City,State,Zip Code): <br /> 1 `c^ Z (D y <br /> X. OUNTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved Sanitary Permit Fee(Includes Groundwater a ssu Issuing a ignalu (No Si <br /> Approved ❑ Owner Given Initial ��Sur^cn�arge reel <br /> A v rs e r in i n 13s,IJ.J <br /> C DITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(formerly Plb-67)(R.11/08) DISTRIBUTION: Original to County,One Copy To:Safety&Buildings Division,Owner,Plumber <br />