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�D1LHR SANITARY PERMIT APPLICATION COUNTY <br /> In accord with ILHR 83.05,Wis.Adm.Code BURR <br /> STATE SANITARLtY PPP'���V MIT#/siq I(_ <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than ❑ /SG�/J l `1710 <br /> 8'%x 11 inches in size. c k It re�lalot(�previous application <br /> -See reverse side for instructions for completing this application. STAT N I.D.NUMBER <br /> I. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION. <br /> PROP RTY OWNER�. PROPERTY LOC TION <br /> S T , N, R7 E(or <br /> PR6PERTY OWNER'S MAILING ADDRESS LOT# BLOCK# <br /> CITY,STATE 21P CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER <br /> CI P,/O 3- <br /> 11. TYPE OF BUILDING: (Check one CIN NEAREST ROAD <br /> ❑State Owned VILLAGE �r°� 7O <br /> ❑ Public 1 or 2 Fam. Dwelling-#of bedrooms 3 e <br /> III. BUILDING USE: (If building type is public,check all that apply) O�L) �j— �—�Cc <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 Bit applicable) <br /> A) 1. ❑ New 2. X 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 Oth,,e��..r,,(( <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. LOADINGRATE 15. PERC.RATE 6. SYSTEM ELEV. 17. FINAL GRADE <br /> REQUIRED(sq.ft.) PROPOSED(sq.ft.) (Gals/day/sq.ft.) (Min./inch) ELEVATION <br /> Feet Feet <br /> VII. TANK CAPACITY Site <br /> in allons Total #of Prefab. Fiber- Exper. <br /> INFORMATION Ma,n4fecturer's Name Con- Steel Plastic <br /> New istin Gallons Tanks W(PS2/ oncrete structed glass App. <br /> Tanks Tanks <br /> Se tic Tank or Hold I ng Tank <br /> Lift Pump TanktSi hon 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:(Namps) MP/MPRSW No.: Business Phone Number: <br /> moo/ 7/5 �1 �F <br /> Plumber's Address(Street,City State,Zip Code): <br /> [KSI <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved Sanitary Permit Fee(Includes Groundwater Date Issued Issuing Sign re(No ps) <br /> 'CG _ ^/_�' <br /> Approved ❑ Owner Given Initial Surcharge Fee) <br /> l7 J1 ✓,I! <br /> Ad Det rminatio <br /> X. CONDITIONS OF APPROVAUREASONS FOR DISAPPROVAL: <br /> SBD-6398(formerly Plb-67)(R.11/88) DISTRIBUTION: Original to County,One Copy To:Safety&Buildings Division,Owner,Plumber <br />