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DILHR SANITARY PERMIT APPLICATION <br /> In accord with ILHR 83.05,Wis.Adm.Code COUNTY <br /> n <br /> STATE SANITAYPERMIT#,,, <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 rev on 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 /> PROPE TY OWNER PROPERTY LOCATION <br /> '/4 ,5�: 'Y4,Sgel T,59, IN, R /`a (or)W <br /> PROPERTY OWN R'S MAI NG ADDRESS LOT# BLOC # <br /> CI Mf ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER <br /> E3 CITY II. TYPE OF BU DING: (Check one <br /> ❑State Owned VILLAGE: NEA ST ROAD <br /> ❑ Public 1R1 or 2 Fam. Dwelling–#of bedrooms.3 <br /> 111. BUILDING USE: (If building type is public,check all that apply) C) .-,>,_ <br /> 1 ❑ Apt/Condo `�V <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 ❑ 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 /> Vs. ABSORPTION SYSTEM INFORMATION: <br /> 1.GALLONS PER DAY 2.ABSORP.AREA 3.ABSORP.AREA 14. LOADING RATE 5. PERC.RATE 16. SYSTEM ELEV. 7. FINAL GRADE <br /> REQUIRED(sq.ft.) PROPOSED(sq.ft.) (Gals/day/sq.ft.) (Min./inch) �7 ELEVATION <br /> 950 Ju�v 5&5 e A111 /,5 Feet 00 Feet <br /> VII. TANK CAPACITY Site <br /> in allons Total #of Prefab. Fiber- Exper. <br /> INFORMATION New istin Gallons Tanks Manufacturer's Name Concrete <br /> Con- Steel glass Plastic App <br /> Tanka Tanks structed <br /> Septic Tank or Holdin Tank <br /> LIR Pump Tank/Siphon Chamber <br /> Vlll. RESPONSIBILITY STATEMENT <br /> I,the undersigned,assume responsibility for installation of the onsite sewage system shown on the attached p lans. <br /> Plumber's Name(Print): Plumber's Signature:(No Stamps) MP/MPRSW No.: Business Phone Number: <br /> e rn �r/t�/� 3311 5 3 <br /> Plumber's Address(Street,City,State,Zip Code): _ <br /> PO 505_/V S o? 1,AJ 72 <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved Sanitary Permit Fee(Includes Groundwater Date Issued Issuing Agi nt ig us Stamps) <br /> d, rcharge Fee) <br /> Approved ❑ Owner Given Initial rt C7Su`cXJ <br /> Adverse i -�P )-�L? I <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,Ow er,Plumber <br />