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DFLHR SANITARY PERMIT APPLICATION <br /> In accord with ILHR 83.05,Wis.Adm.Code D�k r N f 0- <br /> STATESANITAWYPERMIT#IRSS <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than ❑ C ' rJ� <br /> 8'f,x 11 inches in size. Check If rel)n to 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 /> PR PERTY OWNE PROPERTY LOCATION <br /> � t� CK SF ''/e5E ''/a, S 6 TgO, N, R q E(o <br /> PROPERTY OWNER'S MAILING ADDRESS t LOT# / BLOCK# <br /> a 3- a �o=� Lo k-e rut I w <br /> CITY,STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER <br /> VaK v Vr30 V0 <br /> It. TYPE OF BUILDING: (Check one) CITY N REST ROAD <br /> ❑State Owned VILLAGE: s + t "aY1SCr , LK• ^C Iy t /k,4 <br /> ❑ Public CK 1 or 2 Fam.Dwelling-#of bedrooms-3- <br /> Ill. <br /> edroomsIII. BUILDING USE: (It building type is public,check all that apply) © / Q� :�>ao <br /> 1 ❑ Apt/Condo T <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. ❑ New 2. R 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: (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: <br /> 1.GALLONS PER DAY 12.ABSORP.AREA 13.ABSORP.AREA 14. LOADING RATE 5. PERC.RATE 6. SYSTEM ELEV. 7. FINAL GRADE <br /> REQUIRED(sq.ft.) PROPOSED(sq.ft.) (Gals/day/sq.ft.) (Min./inch) �{ pELEEV�ATION <br /> 7�c 7 - � jfo 3-3-3 9 ,, 7SFeet [ d Feet <br /> VII. TANK CAPACITYSite <br /> in al Ions Total #of Prefab. Fiber- Exper. <br /> INFORMATION New istin Gallons Tanks Manufacturer's Name rote Con- Steel glees Plastic App <br /> Tanks Tanks strutted <br /> l <br /> nk or Holdin Tank <br /> Litt Pump Tank/Siphon Chamber <br /> VIII. RESPONSIBILITY STATEMENT <br /> I,the undersigned,assume responsibility for irlstallation of the onsite sewage system shown on the attached plans. <br /> Plumber's Nama(Print): Plum is Signature: No mps) MP/MPRSW No.: Business Phone Number: <br /> e(s /1 (' r htP sz�V /,5- b 664 <br /> Plumber's Address(Street,City,State,Zip Code): <br /> C -ebsJ#r s <br /> IX. (COUNTY/DEPARTMENT USE ONLY <br /> Disapproved Sanitary Permit Fee(Includes Groundwater a e esu Issuing A en gnat (No S ps) <br /> I surcharge Fee) <br /> Approved ❑ Owner Given Initial l C ,may„ `7 �� <br /> Adverse Determination l w /� <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-8398(formerly Plb-67)(R.11/88) DISTRIBUTION: Original to County,One Copy To:Safety&Buildings Division,Owner,Plumber <br />