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DILHR SANITARY PERMIT APPLICATION <br /> In accord with ILHR 83.05,Wis.Adm.Code COUNTY <br /> STATEANITARYl ERMIT# <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than <br /> �og <br /> 8'b x 11 inches in Size. ❑ check if revlsiiooXtto 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. S9 - .10 ' S'7 <br /> PROPERTY OWNER PROPERTY LOCATION rr�� <br /> 6y res+ p 4 SE Y.SWya,S 3�, TtO, N, R E (or W <br /> PROPERTY OWNER'S MAILING ADDRESS LOT# BLOCK# <br /> C d <br /> CITY, AT ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER <br /> Wp I- W i' 5��93 ? ,s y2ro <br /> It. TYPE OF BUILDING: (Check one) ❑ State Owned ITY VILLAGE: NEAREST ROAD <br /> 2 Octa �e-, c A <br /> ❑ Public 1 or 2 Fam. Dwellings of bedrooms A A NUM f� �7 <br /> III. BUILDING USE: (If building type is public,check all that apply) V�- <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. ❑ 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: (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 DAI 2.ABSORP.AREA 3.ABSORP.AREA 4. LOADING RATE 15. PERC.RATE 16. SYSTEM ELEV. 7. FINAL GRADE <br /> REQUIRED(sq.ft.) PROPOSED(sq.ft.) (Gals/day/sq.ft.) Min./inch) ELEVATION <br /> So 3 7S J �� Z - �- y y S S Feet 7,j Feet <br /> VII. TANK CAPACITY <br /> in allona Total #of Prefab. Site Fiber- Exper. <br /> INFORMATION New istin Gallons of Manufacturer's Name Concrete Con- Steel glass Plastic App <br /> Tanks Tanks strutted <br /> tic jgk or Holding Tank i.P Pf^ <br /> itfifF—umpTanilisiptionChamber 00 <br /> VIII. RESPONSIBILITY STATEMENT C77 O <br /> I,the undersigned,assume responsibility for'nstallation of the onsite sewage system shown on the attached plans. <br /> Plumber's Name(Print): Plu er's Si nature.(No nips) MP/MPRSW No.: Business Phone Number: <br /> _e(S t< o ec- 7/r &o of <br /> Plumber's Address(Street,City,State,Zip Code): / <br /> -7 1 S D 2 to r W SY�`r <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved Sanitary Permit Fee(Includes Groundwater Date IssuedIasui g Agent Signature(No Stamps) <br /> Surcharge Fee) <br /> Approved E] Owner Given Initial � �qr-� . <br /> Adv D t rmin i n ROO 00 <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 />