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DILHR SANITARY PERMIT APPLICATION <br /> 7D,I LH- In accord with ILHR 83.05,Wis.Adm.Code couNTvn <br /> TTANIT YPERMIT# yy� <br /> —Attach complete plans(to the county copy only)for the system,on paper not less than b;iI�8'%x11inchesinsize. ckitr $ion 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 PROPERTY LOCATION <br /> L p E — ms's— %, S 14 T Q, N, R 1'7 E (o W <br /> PPERTY OWNER'S MAILING ADDRESS LOT# BLOCK# <br /> S W - gess, 1-K- R P - <br /> CIN,STA E ZIP CODE PHONE NUMBERSU <br /> 13o ov 0 ,1 7. ��l- b 00 <br /> II. TYPE OF BUILDING: (Check one CITY NEAREST ROS j j � �D <br /> State Owned VILLAGE '1 N�O� W f1 <br /> El Public N 1 or 2 Fam.Dwelling—#of bedrooms RIWUOF <br /> PARCELAX NUMBER(5) <br /> Ill. BUILDING USE: (If building type is public,check all that apply) <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. El New 2. lEl 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 /> 11Seepage Bed 21 EJMound 30 EJ SpecifyType 41 ❑ Holding Tank <br /> 12 14 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 PER2.ABSORP.AREA 3.ABSORP.AREA 4. LOADING RATE 5. PERC. RATE 6. SYSTEM ELEV. 7. FINAL GRADE <br /> REQUIRED AREA <br /> ft.) PROPOSED(sq.ft.) (Gals/da /sq.ft.) (Min./inch) 9_ ELEVATION <br /> 3 ID o7 <br /> $0 (O «L 15 ' Feet Feet <br /> VII. TANK CAPACITY Site <br /> in allora Total #of Prefab. Fiber- Exper. <br /> INFORMATION New istin Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App <br /> Tanks Tanks strutted <br /> Septic Tank or Holdina Tank `hi Lt7 <br /> Lift Pum Tank/Si hon 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's Signature:(No temps) MP/MPRSW No.: Business Phone Number: <br /> lumber's Address(Street,City,State,Zip Code): <br /> W sots <br /> IX.I COUNTY/DEPARTMENT USE ONLY1. <br /> Disapproved Sanitary Permit Fee(Includes Groundwater e e ssue Issuing Agent Si ture(Po Sta ) <br /> Surcharge Fee) <br /> pproved ❑ Owner Given Initial <br /> Adverse Determination 1 I D , a101Z) <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 8 Buildings Division,Owner,Plumber <br />