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DILHR SANITARY PERMIT APPLICATION COUNTY <br /> In accord with ILHR 83.05,Wis.Adm.Code -C)U( <br /> STATE SANITARY ROMIT# <br /> —Attach complete plans(to the county copy only)for the system,on paper not less than0 <br /> l�l�) <br /> � <br /> 854 x 11 inches In size. ❑ checCkklit revision 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 /> PROPER OWNER - / PROPERTY LOCATION <br /> C Q N %, S 'I T , N, R E (o W <br /> PROPERTY OWNER'S MAILING ADDRESS LOT# BLOCK# <br /> oUAIVs 12 <br /> CITY,STATE ZIP CODE PHONE NUMBER- 3 SUBDIVISION NAME OR CCM NUMBER <br /> II ❑ State Ow <br /> . TYPE OF BUILDING: (Check one)) lI CITY ' NEAREST ROAD <br /> ned VILLAGEAVL W . \ fauvd 'Ri RD <br /> ❑ Public 1 or 2 Fam. Dwelling–#of bedrooms 2– A LOF' U BER( ) <br /> Ill. BUILDING USE: (If building type is public,check all that apply) <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) 1New 2. ❑ Replacement 3. ElReplacement 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 [1Mound 30 ❑ Specify Type 41 El HoldingTank <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 PER2.ABSORP.AREA 3.ABSORP.AREA 4. LOADING RATE 5. PERC.RATE 6. SYSTEM ELEV. 7. FINAL GRADE <br /> REQUIRED(sq.ft.) PRO OSED(sq.ft.) (Gals/day/sq.ft.) (Min./inch) '�11 ELEVATION <br /> 30 DAY % r 6Z �I- Feet l Feet <br /> VII. TANK ICAPACITY Site <br /> in allons Total #of Prefab. Fiber- Expp. <br /> INFORMATION New istin Gallons Tanks Manufacturer's Name oncret Con- Steel glass Plastic App <br /> a s Tanks strutted <br /> Se tic Tank or Holdin Tank <br /> Litt Pump Tank/Sipon 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 /> I c ARP 90pno Ms $(ob- ylS7 <br /> Plumber's AddressStr at,City,State,Zip Cod6): <br /> 2'l7 �o Rw 35 g3 <br /> /COUNTY/DEPARTMENT USE ONLY <br /> DisapprovedSanitary Permit Fee(Includes Groundwater Date Issued issuing Ae ign re mps) <br /> Approved Owner Given Initial Surcharge Fee) <br /> Adverse <br /> Determin i n <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(formerly Plb-67)(R.11/88) DISTRIBUTION: Original to County,One Copy To:Safety&Buildings Division,Owner,Plumber <br />