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DILHR SANITARY PERMIT APPLICATION <br /> In accord with ILHR 83.05,Wis.Adm.Code COUNTY <br /> STAT ANITA ERMIT#Il l� <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than <br /> 8%x 11 inches in size. ❑ Check if revisit 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 /> PROPE!k OWNER P OPERTY(�LOTCATION <br /> I� .6 '/aJG Ya,S Tq( , N, R 1,- E (or W <br /> PROP ATY 151 wNM IMAILING MR-i REL . LOT# N BLOCK#N <br /> IS�R <br /> ITYOSTATE + IPIOO,DEE� PHONE NUMBER- SUBDIVISION NAME OR CSM NUMBER /v <br /> 1 �116q-70 <br /> II. TYPE OF BUIL ING: (Check one) CITY NE REST ROAD <br /> State Owned VILLAGE : (� _ <br /> ❑ Public X1or2Fam. Dwellingofbedrooms� W TOWN U l} <br /> Ill. BUILDING USE: (If building type is public,check all that apply) as-40o <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 ❑ RestauranUBar/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: (CheckOnI one in line A. Check line B if applicable) <br /> . <br /> A) 1. ❑ New 2Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5.❑ Repair of an <br /> System ystem 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.ySL Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank <br /> 12'KSeepage 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.AS FIR AREA 4. LOADING RATE 5. PERS.RATE 6. SYSTEM ELEV. 7. FINAL GRADE <br /> 3©O REQUIRED(sq.ft.) PROPOSED(sq.ft.) (Gals/day/sq.tt.) (Min./inch) ELEVATION <br /> 30 taq 9 13 '1151y Feet 9'9,D Feet <br /> VII. TANK CAPACITY Site <br /> in allons Total #of Prefab. Fiber- Exper. <br /> INFORMATION New istin Gallons Tanks Manufacturer's Name oncrete Con- Steel glass Plastic App <br /> Tanks Tanks structed <br /> Septic Tank or Holdinct Tank <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): Plumb <br /> er's SigngI ire:(No mps) MP/MPRRSSW No.: Business Phone Number: <br /> ' <br /> Plumbers Address(Street,City, tate,Zip Code): <br /> 2qjU <br /> (An OiW4 :215 A 72[ r <br /> IX. OUNTY/DEPAR MEN USE ONLY iJ <br /> Disapproved f Sanitary Permit Fee(Includesi Groundwater a e ssue Is in Agent Signgt a(No Stamps) <br /> pDroved ElOwner Given Initial �-(suumharge Fee) I h �l <br /> Advers Determination - lJ LJ `v-�-ql [-�l <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 8 Buildings Division,Owner,Plumber <br />