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DILHR SANITARY PERMIT APPLICATION <br /> In accord with ILHR 83.05,Wis.Adm.Code couN <br /> -_�- U r <br /> • � STATE SANITARY7�iRMIT# <br /> -Attach complete plans(to he county copy only)for the system,on paper not less than o,RI(6%0 <br /> ' � <br /> 88%x 11 inches in size. 11Ch k if revislo o previous application <br /> -See reverse side for Instr ctions for completing this application. STATE PLAN I.D.NUMBER <br /> 1. APPLICANT INFORMATI N-PLEASE PRINT ALL INFORMATION. <br /> PROPERTY OWNER PROPERTY LOCATION f q <br /> �Lk T R *{ '% %a, S p <br /> T b , N, R 15 E(or W <br /> PROPERTY OWNER'S MAILING DRESS LOT# 8 BLOCK# <br /> 3 N. GR*G5 v' . <br /> CITY.STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER <br /> ST• PfJU1- . MfJ 104 GI2 0Z <br /> II. TYPE OF BUILDING: (Check one) Lj <br /> CITU NEAR ST R AD <br /> ❑ State Owned n VILLAGE:4409 W: p <br /> ❑ Public A or 2 Fam.Dwelling-#of bedrooms L ( ) <br /> III. BUILDING USE: (If building type is public,check all that apply) <br /> /q — C, —D3— O� <br /> 1 ElApt/Condo 1 <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 (_1 Service Station/Car Wash <br /> 5 ❑ Hotel/Motel 9 ❑ Office/Factory 13 ❑ Other: Specify <br /> IV. TYPPEOF PERMIT: (Check only one in line A. Check line B if applicable) <br /> A) 1.9 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: (Ch k only one) <br /> Non-Pressurized Distribution Pressurized Distribution Experimental Other <br /> 11 IaL Seepage Bed 21 ❑ Mound 30 El Specify Type 41 El 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 12.ASORP.AREA 3.ABSORP.AREA 14. LOADING RATE 15. PERC.RATE S. SYSTEM ELEV. 7. FINAL GRADE <br /> REQUIRED(sq.ft.) PROPOSED(sq.ft.) (Gals/day/sq.ff.) (Min./inch) ELEVATION <br /> 3� L40V Ov �7� .5 Feet //• 0 Feet <br /> CAPACITY <br /> VII. TANKite <br /> e alloI I Total an ProfPfab. Fiber- Exper. <br /> INFORMATION New istin Gallons Tanks Manufacturer's Name oncrete Con- Steel glass Plastic App <br /> Tanks Tanks strutted <br /> Septic Tank or Koldina 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:(Nomps) /MPRSW No.: Business Phone Number: <br /> (( H0.Fk/ s I 9LAMAMI <br /> MP ._.G IS G- 1 1S7 <br /> PI mber's Address(Street,City, tate,Zip Code: <br /> 27 0 flw,4VEB5M W - 54,811 <br /> IX. COUNTYIDEPARTME T USE ONLY <br /> Disapprov San tary Permit Fee(Includes Groundwater a e asu I Agents ature(No Stamps) <br /> Surcharge Fee) <br /> OApproved ❑ Owner Give Initial <br /> Adverse Dt ormination <br /> X. CONDITIONS OF APPR VALIREASONS FOR DISAPPROVAL: <br /> SBD-6399(formerly Plb-67)(R.11/ 1 DISTRIBUTION: Original to County,One Copy To:Safety&Buildings Division,Owner,Plumber <br />