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DILHR SANITARY PERMIT APPLICATION <br /> In accord with ILHR 83.05,Wis.Adm. Code couNTv <br /> I . STATE SAyyyyITA Y PERMT#133r l <br /> —Attach complete plans(to the county copy only)for the system,on paper not less than e7 � � <br /> 8%x 11 inches in size. ❑ Ch frevisiontopr iousapplication <br /> —See reverse side for instructions for completing this application. STATE PLAN I.D.NUMBER <br /> I. APPLICANT INFORMATION—PLEASE PRINT ALL INFORMATION. <br /> PROPS TY OWNER PROPERTY LOCATION <br /> 5F_% ,5&4, S,,O T , N, R 15 E (orye <br /> PROPERTY OW ER'S MAILING ADDRESS LOT# BLOCK# <br /> CITY STATE ZIP C DE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER <br /> bt/ S <br /> It. TYPE OF BUILDING: (Check one) ❑State Owned CITY :VILLAGE L-5 N AR R AD <br /> Public ❑1 or 2 Fam. Dwelling—#of bedrooms PAKULL I AX Nu e <br /> 111. 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) Qa <br /> e <br /> A) 1. ❑ New 2. ❑ Replacement 3. ❑ Replacement of 4.10 Reconnection of 5.I�Uj Repair of an 7�w <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 ❑ 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: t 5 ^t ') � Q <br /> 1.GALLONS PER DAY 2.ABSORP.AREA 3.ABSORP.AREA 4. LOADING RATE 5. PERC.RATE 6. SYSTEM ELEV. 7. FINAL GRADE <br /> REQUIRED(sq.ft.) PROPOSED(sq.ft.) (Gals/day/sq.ft.) (Min./inch) ELEVATION <br /> Feet Feet <br /> VII. TANK CAPACITY Site <br /> in allons Total #of Prefab. 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 Holding Tank <br /> Litt Pump Tank/Si hon Chamber <br /> Vlll. 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' Signature: oStamps MP/MPRSWNo.: Business Phone Number: <br /> ZZ Z - <br /> umber's Address(Street,City,State,Zip Code): <br /> IX COUNTY/DEPARTMENT USE ONLY <br /> El Disapproved Sani ryPermit Fee(Includes Groundwater Date Issued Iss Agent St gn tura(No Stamps) <br /> Approved F-1Owner <br /> Fee) <br /> Owner Given Initial ��5 . /� (yJ <br /> Adverse Dt min tion Vv <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: 77 7 <br /> SBD-6398(formerly Plb-67)(R.11/89) DISTRIBUTION: Original to County,One Copy To:Safety&Buildings Division,Owner,Plumber <br />