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DILHR SANITARY PERMIT APPLICATION CDU r <br /> In accord with ILHR 83.05,Wis.Adm.Code <br /> STATE AR PERMIT#)qr, ) <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than <br /> 8'%x11inches insize. ❑ / c�-77-� 1 <br /> Ifrevisi ropreviousapplication <br /> -See reverse side for instructions for completing this application. STATE PIAN I.D.NUMBER <br /> I. APPLICANT INFORMATION—PLEASE PRINT ALL INFORMATION. <br /> PROPERTY OWNER PROPERTY LOCATION <br /> '/4 ''/4, S S T40 , N, R E(Or W <br /> PRO ERTV WNER'S MAILIN ADDRESS LOT# BLOCK# <br /> 0 - <br /> CITY,STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER <br /> N nl Z <br /> II. TYPE OF BUILDING: (Check one) CITY NEAREST ROAD <br /> ��qq ❑State Owned VILLAGE 5(�� <br /> ❑ Public 91 or 2 Fam. Dwelling,#of bedrooms S EL BER( <br /> III. BUILDING USE: (If building type is public,check all that apply) (��01-700 <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. tK13splacement 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 Usl 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. 7. FINAL GRADE <br /> REQUIRED(sq.ft.) PROPOSED(sq.ft.) (Gals/day/sq.ft) (Min./inch) Q/ELEV�A7TION <br /> n <br /> (5U IZ00 V2-.o(, ,(p L `741 ( Feet f bi ( Feet <br /> VII. TANK CAPACITY Site <br /> in allons Total #oT Prefab. Fiber- Exper. <br /> INFORMATION New is[in Gallons Tanks Manufacturer's Name ncret fin- Steel glass Plastic App <br /> Tanks Tanks strutted <br /> Septic Tank or Holdin Tank <br /> Lift Pum Tank/Siphon 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:(No mps) MP/MPRSW No.: Business Phone Number: <br /> )C p `t 2 S Qfo6- y <br /> u ber's AddressS reet,city,sts ,zip <br /> Z 1(ao w 3s SBSi 4.11 5`t <br /> IX. OUNTY/DEPARTMENT USE NLY <br /> ❑ Disapproved Sanitary PermitFee(Includea Groundwater Date Issued Issuing Agent,Slgnat re(No Sta ps) <br /> Sumharge Fee) <br /> Approved 1-1 Owner Given Initial eft 13S <br /> Adv Determination <br /> --lf <br /> X. C N\SDITn10NS OF eR QVna <br /> / REA FOR DISAPPROVAL: <br /> inw�r) Ceue r d OCd Plre a f <br /> I <br /> SBD-6398(formerly Plb-67)(R.11/88) DISTRIBUTION: Original to County,One Copy To:Safety&Buildings Division,Owner,Plumber <br />