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assassas <br /> DILHR SANITARY PERMIT APPLICATION <br /> In accord with ILHR 83.05,Wis.Adm.Code COUNTY <br /> J <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than C I &s9q \STATE SANITARY PERMIT#Igo)3 <br /> 8'/z x 11 inches in size. C. <br /> Check if revision to vious 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 /> PROPERTY OWNER PROPERTY LOCATION <br /> IAM S M ( r_747— Ya, S T N, R 1,5 E(or nW <br /> PROPERTY OWNER'S DRESS/1 LOT# <br /> L?J ' _ l.. �V L• �-O d <br /> C_ ITV STATE ZIPC 2E PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER <br /> \�n\w� <br /> 11. TYPE OF BUILDING: (Check one) State Owned CITY NEAREST ROAD <br /> VILLAGE_KKS071 <br /> ❑ Public 14 1 or 2 Fam.Dwellings of bedrooms Z A L I Ax NUMB R(b) <br /> 111. BUILDING USE: (If building type is public,check all that apply) I — -�-��— W--KOD <br /> 1 ❑ Apt/Condo <br /> 2 El 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: (Chechonly one in line A. Check line B if applicable) <br /> A) 1. ❑ New 2.y7A-(��I Replacement 3. El 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 El 30 ❑ Specify Type 41 El 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 PE7 2.ABSORP.AREA 3.ABSORP.AREA 14. LOADING RATE 15. PERC.RATE 16. SYSTEM ELEV. 17. FINAL GRADE <br /> REIR D(sq.ft.) PROPOSED(sq.ft.) (Gals/ a /sq.ft.) (Min./inch) �{ ELEVATION <br /> �o 0 t 3_ / Feet 10^Z_Feet <br /> CAPACITY <br /> VII. TANK in allons Total #of Prefab. Site 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 Holdin Tank — <br /> Lift Pum 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's Signature:(No Stamps) MP/MPRSW No.: Business Phone Number: <br /> 1C OPC — 1 6� �IIS <br /> Plumber's Address(Street City State,Zip CodeT: <br /> 'Z �v 35 WBS76R I - 3q8q <br /> IX COUNTY/DEPARTME T USE ONLY <br /> ❑ Disapproved Sanitary Permit Fee(Includes Surcharge FeeGroun)dwater a e IssuedIssui gent Sig ure(No Stamps) <br /> proved ❑ Owner Given Initial 13� � ��-r.�•1 <br /> Adverse Determination <br /> X. CON ITIONS 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 />