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DILHR CdSANITARY PERMIT APPLICATION <br /> In accord with ILHR 83.05,Wis.Adm.Code <br /> couNTr <br /> s � pp�7p <br /> STATE/�,nNITARY MIT"o2OJ0 /0 <br /> —Attach complete plans(to the county copy only)for the system,on paper not less than U'�7Lj <br /> 8%x 11 inches in size. ❑ Check if revisio 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 /> PROPERTY OWNER PROPERTY L TION <br /> V/1/4 '/4,,SN, R & E(or(w <br /> PROPERTY OWNER'S MAILING ADDRESS LOT N BLOCK/f <br /> 650 Lf T I C <br /> CITY,STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER <br /> m is4c-505 <br /> 11. TYPE OF BUILDING: (Check one) State Owned VILLAGE CITY NEAREST ROAD <br /> ❑ -- <br /> ��ppyy a .Scn/ o, <br /> ❑ l� <br /> Public 1 or 2 Fam.Dwelling—#of bedrooms NUM ( nn <br /> III. 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 ❑ Other: Specify <br /> IV. TYPE OF PERMIT: (Check only one in line A. Check line B if applicable) <br /> A) 1. d 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 DAY 2.ABSORP.AREA 13.ABSORP.AREA 14. LOADINGRATE 5. PERC.RATE 6. SYSTEM ELEV. 7. FINAL GRADE <br /> REQUIRED(sq.ft.) PROPOSED(sq.ft.) (Gal /day/sq.ft.) (Min/inch) �,y ELEVATION <br /> Lisp o /Z0 r Z —1 S9 • 1 Feet .5 Feet <br /> CAPACITY <br /> VII. TANK Site <br /> INFORMATION in gallons Total #OfTanks <br /> Prefab. Fiber- App. <br /> New xistin Gallons Tanks Manufacturer's Name ConcreteCon- Steel glass Plastic App <br /> Tanks Tanks structed <br /> Septic Tank or Holdino Tank 1 0 k <br /> Lift PUMP Tank/Siphon 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): 1 Plumber's Signature:(No mps) MP/MPRSW No.: Business Phone Number: <br /> Plumber's Address(street,City,State,Zip Code): <br /> 27 o N �",i i. .5 <br /> IX. COUNTYIDEPARTMENTIUSE ONLY <br /> ❑ Disapproved Sanitary Permit fee(Includes Groundwater Date IssuedIssuin Agent Signature(No Stamps) <br /> (�5 Suroharge Fee) pp22 <br /> ALl pproved ❑ Owner eDeermin 6-00 <br /> Adverse Determination rmination llJ <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 />