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DILHR SANITARY PERMIT APPLICATION <br /> In accord with ILHR 83.05,Wis.Adm. Code COUNTY <br /> STATESANITARY PERMIT )80l <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than I `/'yt�� 1�V <br /> 8%x 11 inches in size. ❑ Checkifas previous application <br /> -See reverse side for Instructions for completing this application. STATE—PL AN I.D.NUMBER <br /> 1. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION. <br /> PROPERTY OWNER PR RTYLOCATION �� <br /> CAARLEs LoofR M ER '/4, S r,,J T (, N, R E(or W <br /> PROPERTY OWNER'S MAILING ADDRESS LOT# 1il1164mill <br /> 53o c ) D2- G i-- <br /> CITY,STATE ZIP CODE PHONE NUMBER SUB IVISION NAME OR CSM NUMBER <br /> Ig .SS343 ' 3'l Cs Q P1 <br /> If. TYPE OF BUILDING: (Check one) CITY N REST ROAD <br /> ❑ State Owned � VILLAGE (� I� I D� 1h1 A RID - <br /> ❑ Public 1 or 2 Fam. Dwelling,#of bedrooms_ 40 OF Ax NUUM E <br /> III. BUILDING USE: (If building type is public,check all that apply) 3 �-� � i0 _/-..�/ -/'1v�J� <br /> 1 El 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./U�C"I 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 /> N''on,,,-PPressurized 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 2.ABSORP.AREA 3.ABSORP.AREA 4. LOADING RATE 5. PERC.RATE 6. SYSTEM ELEV. 7. FINAL GRADE <br /> 7\�7V� REOIy/RED(sq.ft.) PROPOSED(sq.ft.) (Gals/day/sq.ft.) (Main./inch) ` ELEVATION <br /> "'- 17- 20 (07- J �`� Feet D Feet <br /> CAPACITY <br /> VII. TANK Site <br /> in allons Total #of Manufacturer's Name Prefab. Con- Steel Fiber- plastic Exper. <br /> INFORMATION New istin Gallons Tanks oncret glass App. <br /> Tanks Tanks strutted <br /> Septic Tankor Holding Tank (7 <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): Plumber'p Signature:(No Stamps) MP/MPRSW No.: Business Phone Number: <br /> ICI+I�QD 3 26 �� 0(46— I� <br /> P mber's Address(Street,City,State,Zip Code). <br /> rL'1`160 <br /> Hwy 35 WV_ZSf'1_-, R W 1 . <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved Sanitary Permit Fee(Includes Groundwater a a IssuedIssui gent Sig re(No Stamps) <br /> proved ❑ Owner Given Initial c8 Surcharge Fee) <br /> Adverse Determination <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-8398(formerly Plb67)(R.11/88) DISTRIBUTION: Original to County,One Copy To:Safety&Buildings Division,Owner,Plumber <br />