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1J DILHR SANITARY PERMIT APPLICATION COUNTY . <br /> In accord with ILHR 83.05,Wis.Adm.Code u r <br /> 09 <br /> �I;�� ,� <br /> —Attach complete plans(to the county copy only)for the system,on paper not less than ❑STATE SANITARY PERMIT#/`r�`Y <br /> 8'%x 11 inches in size. c k revlalo <br /> previous application <br /> -See reverse side for Instructions for completing this application. STATE PLAN I.D.NUMBER <br /> 1. APPLICANT INFORMATION—PLEASE PRINT ALL INFORMATION. <br /> PRO ERTY OWNERPROPERTY LOCATION <br /> LX '/a )''/a, S T40, N, R E(O W <br /> PROPERTY rER'S MAILING ADDRESS LOT# .-� BLR# <br /> CITY,ST TE Cy ZIPI(`O-O,P-f PHONE NUMBER SUB_DI\VISIIOOGN NAME ORtCSM N BER ThSr <br /> Mk� <br /> 7A r <br /> II. TYPE OF ILDING: (Check one) ❑ State Owned El CITYVILLAGE Ill OF' <br /> / (`7 EARES AD n� <br /> ElPublic1 or 2 Fam. Dwellings of bedrooms A LAX NU K <br /> ve— <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. TYPE OF PERMIT: (Check only one in line A. Check line B if applicable) <br /> A) 1.Jal New 2. ElReplacement 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: (Check only one) <br /> Non-Pressurized Distribution Pressurized Distribution Experimental Other <br /> eepage Bed 21 El Mound 30 ❑ Specify Type 41 El HoldingTank <br /> 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.ABSORP.AREA 3.ABSORP.AREA 4. LOADING RATE 5. PERC.RATE 6. SYSTEM ELEV. 7. FINAL GRADE <br /> f� <br /> O /d <br /> REQUIRED(sq.ft.) PROPOSED((sq.ft.) (Gals/day/sq.ft.) (Min./inch) / ELEVATION <br /> 9 IG- z•� Feet VA.oFeet <br /> VII. TANK CAPACITY Site <br /> ingallops_ Total #of Manufacturer's Name Prefab. Con- Steel Fiber- plastic Exper. <br /> INFORMATION New istin Gallons Tanks oncret glass App. <br /> Tanks Tanks structed <br /> Septic Tank or Holdino 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:(No S ps) MP/MPRSW No.: Business Phone Number: <br /> kc oPK 03� 15 IS'1 <br /> Plumber's Address(Street,City,State,Zip Code): <br /> 21 &c) \),_A, 3e� 05'ktL W1 sgsr)_5 <br /> COUNTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved Sanitary Permit Fee(Includes Groundwater a e ssue Issu' g gent Si a re(No Stamps) <br /> I IL <br /> 0�pproved ❑ Owner Given Initial 1 n�a Suronarge Fee) 7� <br /> Adverse <br /> v Determination V <br /> X. CONDITIONS OF APPROVALIREASONS FOR DISAPPROVAL: <br /> SBD-6398(formerly Plb67)P.11/88) DISTRIBUTION: Original to County,One Copy To:Safety&Buildings Division,Owner,Plumber <br />