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47 SANITARY PERMIT APPLICATION couNTv <br /> DILHIR In accord with ILHR 83.05,Wis.Adm. Code <br /> STAT SANIT YPERMIT# <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than I8114 ��d3 <br /> 8%x 11 inches in size. ❑ Check if revision to previous 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 /> n <br /> D K + eccS'�hrc ( NW'/a E'/a, S a� T 3oN, R �► <br /> PROPERTY OWNER'S MAILI ADDRESS LOT# BLOCK# <br /> ga97 WgMO1.4. V-oe <br /> CITY,STATE ZIP CODEPHONE NUMBER SUBDIVISION NAME OR OSM NUMBER <br /> S I re Ul ` IS947 <br /> LJ CITY NEAREST ROAD <br /> 11. TYPE OF BUILDING: (Check one) pp I <br /> ❑State Owned ❑ VILLAGE :rV TOWN F14 t e LS W a 1 do r4, <br /> ❑ Public [K 1 or 2 Fam.Dwelling-#of bedrooms 3 PAR ELTAX NUMBER( ) ` <br /> III. BUILDING USE: (It building type is public,check all that apply) 066 -' j z)1 <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. N 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.AREA3.ABSORP.AREA 14. LOADING RATE 5. PERC.RATE 6. SYSTEM ELEV. 17. FINAL GRADE <br /> ,� REQUIRED(sq.ft.) <br /> PROPOSED(sq.Vt.) (Gals/day/sq.ft.) (Min./inch) pELEVATION <br /> ( <br /> l � 641-3 &T 96, Feet / •.r Feet <br /> VII. TANK CAPACITY Site <br /> in allons Total #of Prefab. Fiber- Exp . <br /> INFORMATION New xistin Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App. <br /> strutted <br /> Tanks Tanks <br /> eticT or Holdino Tank _60 t>PSR Fj F1 Ll <br /> Gift 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 Pra�t):ePI bar's Signatu :(N Stamps) MP/MPRSW No.: Business Phone Number: <br /> e�S -or r <br /> i MP S? lis 2664(kr <br /> Plumber's Address(Street, 11y,State,Zip Code): <br /> S- G led- -D 1jje6s4— (,cJt' St�8r3 <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved Sanitary Permit Fee (Includes Groundwater a e ssue Issu g ent Sig to ( tamps) <br /> Scharge Fee) <br /> ,Approved ❑ Owner Given InitialI <br /> Adverse Determination J <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(R.08/93) DISTRIBUTION: Original to County,One Copy To:Safety&Buildings Division,Owner,Plumber <br />