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DILHR SANITARY PERMIT APPLICATION <br /> In accord with ILHR 83.05,Wis.Adm.Code ""' <br /> �• � STATE�ANITARVRMIT#/5////n <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than C 155r� tt <br /> 8%x11inches Insize. ❑ CheckIfrevisio 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 PROPERTY LOCATION <br /> ` T�/O, N, R E (or <br /> PROPS)ITY OWNER'S MAILING ADDRESS LOT# / BLOCK# <br /> CITY,STATE I XIP CODE I PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER <br /> 55 5 - %Vo <br /> If. TYPE OF UILDIN (Check one) CITY NEAREST ROAD <br /> ❑State Owned VILLAGE <br /> ❑ Public IX 1 or 2 Fam. Dwelling-#of bedrooms UMB R(b)) <br /> 111. BUILDING USE: (If building type is public,check all that apply) [ _ `'Y 3S3— (:)6)— //(D <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: (Check only one in line A. Check line 8 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 ❑ Seepage Bed 21Mound 30 ElSpecify 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 j2.ABSORP.AREA 13.ABSORP.AREA 14. LOADING RATE 15. PERC.RATE 6. SYSTEM ELEV. 7. FINAL GRADE <br /> REQUIRED(sq.ft.) PROPOSED(sq.ft.) (Gals/day/sq.ft.) (Min/i h) ELEVATION <br /> Feet Feet <br /> VII. TANK CAPACITY Site <br /> in al Ions Total #of Prefab. Fiber- Exper. <br /> INFORMATION New istin Gallons Tanks Manufacturer's Name oncret Con- Steel glass Plastic App <br /> Tanks Tanks strutted <br /> Septic Tank or Holding Tank <br /> Lift Pump Tank/Siphon Chamber <br /> Ll <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 Stamps) MP/MPRSW No.: Business Phone Number: <br /> Gz / � J3 / 3 - ' <br /> Plum is A dress(Street,CityS te, ip Code): <br /> $X.1UN DEPARTMENT USE ONLY <br /> ❑ Disapproved I Sanitary Permit Fee(Ixludes Groundwater Date issuedIssuing ant Signature(No Stamps) <br /> Approved <br /> El Given Initial 14 m �-y� surcharge Feel c <br /> Adverse Determination ` -�� v V <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-8398(formerly Plb-67)(R.11/88) DISTRIBUTION: Original to County,One Copy To:Safety&Buildings Division,Owner,Plumber <br />