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DILHR SANITARY PERMIT APPLICATION COUNTY <br /> ) <br /> F_ In accord with ILHR 83.05,Wis.Adm.Code <br /> STATES ITARV WRMIT#1 0 <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than 05 <br /> 8%x 11 inches in size. 0 ChbckIf 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 /> PROPERTY OWNER PROPERTY LOCATION <br /> 'f/4, S2 T Q, N, R E(or W <br /> PROPERTY OWNER'S MAILING ADDRESS LOT# BLOCK# <br /> 2"15Z© 1.t. <br /> CITY,STATE ZIP C DE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER <br /> b-51 0L . I C o <br /> ❑ <br /> IL TYPE OF BUILDING: (Check one) State Owned CITU NEARES OAD VILLAGE' O CO rX-D <br /> ❑ Public X1or2Fam. Dwelling-#ofbedrooms— A L TAX NUMBER(S) <br /> III. 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. TYP2 OF PERMIT: (Check only one in line A. Check line B if applicable) <br /> A) 1.��Q/New 2. ❑ Replacement 3. ❑ Replacement of 4. El 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 21,1751 Mound 30 ❑ Specify Type 41 F-1Holding Tank <br /> 12 ❑ Seepage Trench 22 n-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 4. LOADING RATE 5. PERI.RATE 6. SYSTEM ELEV. 7. FINAL GRADE <br /> ^^ REQUIRED(sq.ft.) PROPOSED(sq.ft.) (Gals/day/sq.ft.) (Min./Inch) ELEVATION <br /> 3 c>c) LJ� 2 0 d• Feet Feet <br /> VII. TANK CAPACITY r Site <br /> in allona Total #of Prefab. Fiber- Exper. <br /> INFORMATION New satin Gallons Tanks Manufacturer's Name on re Con- Steel glass Plastic App <br /> Tanks Tanks strutted <br /> Septic Tank or Holding Tank 100c>1 (d�� <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 S ps) MP/MPRSW No.: Business Phone Number: <br /> 'PODERluQ3 (1Cxo(o' <br /> Plumber's Address(S reel,City,State,Zip Code): <br /> 2 `ZV) w 35 <br /> I OUNTYIDEPARTM NT USE ONLY <br /> ❑ Disapproved Seni ry Perms[Fea(lnclutlee Groundwater a e esus Isau g ant Signalur Stamps) <br /> ���• �rcherge Fee) <br /> Approved ❑ Owner Given Initial <br /> Adverse Dt rmination <br /> X. C NDITIONS 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 />