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DILHR SANITARY PERMIT APPLICATION COUNTY <br /> In accord with ILHR 83.05,Wis.Adm.Code <br /> .e..� s• STATES NITARY PEk1MIT# <br /> —Attach complete plans(to the county copy only)for the system,on paper not less than / 7 / <br /> 8'%x 11 inches in size. 1:1CU/ revisio 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 /> G7K QG� NG'%tj e%, S Q T , N, R W <br /> P OPERTY OWNER'S MAILING ADDRESS LOT# BLOCK# <br /> 3 I <br /> CITY,STATE ZIP CODEP MBER SUBDIVISION NAME OR c§M NUMBER <br /> ¢r t/ lr *- GYI SSl l 633 w (f�ov 1.01- <br /> ly <br /> 11. TYPE OF BUILDING: (Check one NEAREST ROAD <br /> LJ Owned VILLLAGE De H1 V(s A4v8 4A2K <br /> fM TOWN OF: <br /> ❑ Public ®1 or 2 Fam.Dwelling-#of bedrooms -P-ARCEL TAX Nu R( <br /> Ill. BUILDING USE: (If building type is public,check all that apply) 006,c�7 17 DL_ HW <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. tk 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 12. <br /> REQUIRED(sq.ft.) PROPOSED sgEft) 4 (GaAsday/sq.ft) 5• ((MRCi RATE E <br /> )TE 6. SYSTEM ELEV. 7. ELEVATION <br /> Feet Feet <br /> CAPACITY Site <br /> VII. TANK Prefab. Fiber- Expp. <br /> in Ions Total #of Manufacturer's Name Con- Steel Plastic <br /> INFORMATION New xistin Gallons Tanks Concrete structed glass App. <br /> Tanks I Tanks <br /> .Septic Tank Holdin Tan ZEe'V Z IBS " <br /> Lift Purno Tank/Siphon Chamber <br /> Vlll. RESPONSIBILITY STATEMENT <br /> 1,the undersigned,assume responsibility f r installation of the onsite sewage system shown on the attached plans. <br /> Plumber's Name(Print): PI Der's S nature (No mps) MP/MPRSW No.: Business Phone Number: <br /> I_Js evotay, GuP S7S?c <br /> Plumber's Address p7et,City,State,Zip Code): <br /> IX. OONJpTY/DECPARTMENT USE ONLY r/Un w t <br /> ❑ Disapproved Sfl Very Permit Fee(Includes Groundwater a e ssue Issuing Agent Si natur (No S ) <br /> Surcharge Fee) <br /> Approved ❑ Owner Given Initial I OC 5 ay�l <br /> Adverse Determination y i n ` —J <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6388(formerly Plb.87)(R.11/88) DISTRIBUTION: Original to County,One Copy To:Safety&Buildings Division,Owner,Plumber <br />