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DILHR SANITARY PERMIT APPLICATION COUNTY r <br /> In accord with ILHR 83.05,Wis.Adm.Code <br /> • � STATESANITARY ERMIT#�I� <br /> -Attach complete plans(tot a county copy only)for the system,on paper not less than ❑ �� � <br /> 8%x 11 inches In size. eck f rev sio previous application <br /> –See reverse side for InstrU Dtions for completing this application. STATE PLAN I.D.NUMBER <br /> I. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION. <br /> PROPERTY OWNER PROPERTY LOCATION <br /> CHARLES ` teM '/a '/4,S I T L(O , N, R IS E (or)W <br /> PROPERTY OWNER'S MAILING A DRESS LOT# BLOCK# <br /> Zq f�oRo v'-E . -)- <br /> CITY,STATE EIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER <br /> 'PA tsBusZbSl- `�S30 7(5 259-W-17 <br /> II. TYPE OF BUILDING: (C eck one) Lj CITY NEAREST ROAD <br /> ❑State Owned VILLAGE �fl��tJ FbKv <br /> ❑ Public _�J 1 or 2 Fam.Dwelling-#of bedrooms // <br /> III. BUILDING USE: (If build ng type is public,check all that apply) 10 — 0 , 1G1 <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: (Che k only one in line A. Check line B if applicable) <br /> A) 1. ❑ 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 ck only one) <br /> Non-Pressurized Distribution Pressurized Distribution Experimental Other <br /> 11 ® Seepage Bed 21 ❑ Mound 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.A SORP.AREA 3.ABSORP.AREA 4. LOADING RATE 5. PERC.RATE 6. SYSTEM ELEV. 17. FINAL GRADE <br /> RE UIRED(sq.ft.) PROPOSED(sq.ft.) (Gals/day/sq.ft.) (Min./inch) p ELEVATION <br /> -�jp0 o L{$(- .ia2 -3 12-- ( Feet IpS'0 Feet <br /> VII. TANK CAPACITY Site <br /> in allons Total #Of Prefab. Fiber- Exper. <br /> INFORMATION New iss Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App <br /> Tanks Tanks strutted <br /> Septic Tank or Holdin Tank I C.17 <br /> Lift Pum Tank/SI hon Chamber I -" 5_00 I TMG <br /> VIII. RESPONSIBILITY STJ TEMENT <br /> I,the undersigned,assume r sponsibility 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 /> 'Klck�fwD R vmil IrZwt u R 3 42.L 7rs 866- Lf(s7 <br /> Plumber's Address(&rest,City, tate,Zip Code): <br /> 2'I-160 Nw --35 \,J't8s Fg1 t,3\- 54S93 <br /> IX.,COUNTYIDEPARTME USE ONLY <br /> ❑ --- <br /> Disapprove Sanitary Permit Fee(Includes Groundwater a e esus Issuing Agent Signature(No Stamps) <br /> Suroharge Fee) <br /> Approved ❑ OwnerD Initial ��� /`PD <br /> Adverse D rminati n l�J r^ <br /> X. CONDITIONS OF APPR VALIREASONS FOR DISAPPROVAL: <br /> SBD-6398(formerly Plb-67)(R.11/ ) DISTRIBUTION: Original to County,One Copy To:Safety&Buildings Division,Owner,Plumber <br />