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DILA-IR SANITARY PERMIT APPLICATION COUNTY�r ^ I <br /> In accord with ILHR 83.05,Wis.Adm.Code 'r <br /> STATE,SANI�A PERMIT#a)&qq3 <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than C/I , <br /> 8%X11inches Insize. ❑ Check 11 revs ontoprevious application <br /> LSee reverse side for instructions for completing this application. STATE PLAN I.D.NUMBER <br /> I. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION. 'I- <br /> PROPERTY OWNER PROPERTY LOCATION <br /> Ulm �� G DRESS 6& % 4'7 t/4,S !O T N, R / E(o6W <br /> PROPERTY OWNEI SMAILINLOT# BLOCK# <br /> 36 F•a5 LJf}rrlEKoGot/ RD, <br /> CIJ,v,STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER <br /> �J/4r� i �f1a 3V larc <br /> Lj CITY NEAREST READ <br /> 11. TYPE OF B LDING: (Check one) ❑State Owned VILLAGE: kll t A140lt=Af4ke-4 1 94b . <br /> Pubi9"�_ 511 or 2 Fam.Dwelling-#of bedroom PWATiRL YARNUIVIE <br /> Ill. 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 JZ Other: Specifye!M �6 '� <br /> IV. TYPE OF PERMIT: (Check only one in line A. Check line B if applicable) <br /> A) 1. ❑ New 2.M 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 /> 11Seepage Bed 21 ❑ Mound 30 El Specify Type 41 ❑ Holding Tank <br /> 12 eepage 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 DAI 2.ASSORP.AREA 3.ABSORP.AREA 14. LOADING RATE 15. PERC.RATE 6. SYSTEM ELEV. 7. FINAL GRADE <br /> REQUIRED(sq.ft.) PROPOSED(sq.ft.) (Gals/day/sq.ft.) (Min./inVc) ELEVATION <br /> 1200 7/J !? ZS ' Feet 9Ss met <br /> VII. TANK CAPACITY Prefab. Site Fiber- Exper. <br /> in allons Total #of Manufacturer's Name Concrete Con- Steel glass Plastic App <br /> INFORMATION / New istin Gallons Tanks strutted <br /> / Tanks Tanks <br /> Septic Tank or Hold! Tank 1 /� 2y/s a` W4ffh-_ �t� <br /> Lift Pum 7ank/Si hon Chamber /fid <br /> F1 FI <br /> VIII. RESPONSIBILITY STATEMENT <br /> I,the undersigned,assume responsibility for installation of the onsite sewage system shown on the attached plans. <br /> Plu ,is Name(Print): Plu natur :(N S MP/MPRSW No.: r <br /> ness Phone Number: <br /> o fes° T 3o'7z— w f uiY 3Sa <br /> Plumber's Address(Street,City,State,Zip Code): <br /> ( ? !3 35— <br /> IX. COUNTY/DEPARTME USE ONLY <br /> Disapproved Sani��[ggary Permit Fee(Includes Groundwater a e sou Isaui �entSipnjpure(No Stamps)}� Surcharge Fee) <br /> VAppro7,ed [:] Owner Given Initial <br /> —Iwi <br /> Adverse eter inti n <br /> X. CONDITIONS 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 />