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DILHR SANITARY PERMIT APPLICATION - COUNTY <br /> In accord with ILHR 83.05,Wis.Adm.Code ��I�C <br /> • � STATES NITAR(PERMIT <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than 16077 <br /> j <br /> 8'%x 11 inches in size. ❑ c 6 eck revs n 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 PROP RTY LOCATION <br /> o 6,0 '/4,S / ' T 3 g , N, R / (o W <br /> PROPERTY OWNER'S MAILING ADDRESS LOT# BLOCK# <br /> .;Zq3o Ac^p NA I IVA <br /> CITY,STATE �� 11 ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER <br /> It. TYPE OF BUILDING: (Check one) ❑State Owned CITY <br /> TMLAGE :DE Id Er EST <br /> ❑ Public 1 or 2 Fam. Dwelling-#of bedrooms,-j-- LTAXNU ( ) <br /> III. BUILDING USE: (If building type is public,check all that apply) OO—c I -7_ Q � <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. ❑ 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 L�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 3.ABSORP.AREA 4. LOADING RATE 5. PERI.RATE 6. SYSTEM ELEV. 7. FINAL GRADE <br /> REQUIRED AREA <br /> ft.) PROPOSED(sq.ft.) (Gals/day/sq.ft.) (Min./inch) ELEVATION <br /> q.7o 7o20 71P.0 /01 /O , Feet O Feet <br /> VII. TANK CAPACITY Site <br /> in allons Total #of Prefab. Fiber- Exper. <br /> INFORMATION New xistin Gallons Tanks Manufacturer's Name oncret Con- Steel glass Plastic App <br /> Tanks Tanks strutted <br /> Se tic Tank or Holdino Tank <br /> Litt 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 /> Plumbers Name(Print): Plumber's Signature:(No Stamps) 4P/MPRSW No.: Business Phone Number: <br /> r . 3e, —'22 Q <br /> P umber's Address(Street, try, te,Zip Code): <br /> AAQ , sivezI ZAkz- <br /> IX. OUNTY/DEPARTMENT USE ONLY <br /> Lj Disapproved Sanitary Permit Fee(ISurcharge Feel <br /> ncludes Groundwater a e ssu Issui ent Sipjt re(No Stamps) <br /> Approved ❑ Owner Given Initial c{f (O _'� <br /> Adv t rmin i �f <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(formerly Plb-67)(R.11/88) DISTRIBUTION: Original to County,One Copy To:Safety&Buildings Division,Owner,Plumber <br />