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O DILHR SANITARY PERMIT APPLICATION COUNTY <br /> In accord with ILHR 83.05,Wis.Adm.Code <br /> �� s• � STATE SANITARY PERMIT# I3 S <br /> —Attach complete plans(to the county copy only)for the system,on paper not less than (/ I LA <br /> 8'%x 11 inches in size. ❑ Check if Tevision to previous application <br /> —See reverse side for instructions for completing this application. STAjJEpPLAN I.D.NUMBER <br /> I. APPLICANT INFORMATION—PLEASE PRINT ALL INFORMATION. l6' ton <br /> PROPERTY OWNER PROPERTY LOCATION <br /> 5kr�e1Un✓ts vtc r KW 1/4 OLO 1/4,S 12- T 3q, N, R 14 W <br /> PROPERTY OWNER'S MAILING ADDRESS LOT# BLOCK# <br /> HCR 59 -1314 1315 <br /> CITY,STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER <br /> fie 00ne4, lit 94501 <br /> 11. TYPE OF BUILDING: (Check one) CITY NEAREST ROAD <br /> ❑ State Owned O VILLAGE M TOWN QF -& C f t <br /> ® Public ❑1 or 2 Fam. Dwelling-#of bedrooms— PARCEL TAuM ( ) <br /> 111. BUILDING USE: (If building type is public,check all that apply) O y, _ 311 2 —QZ' ZOO <br /> 1 19 ApVCondo <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 /> VI. ABSORPTION SYSTEM INFORMATION: <br /> 1.GALLONS PER DAY 2.ABSORP.AREA 13.ABSORP.AREA 14. LOADING RATE 5. PERC.RATE 6. SYSTEM ELEV. 17. FINAL GRADE <br /> REQUIRED(sq.ft.) PROPOSED(sq.ft.) (Gals/day/sq.ft.) (Min./inch) ELEVATION <br /> 1540 /9aS /9a5 S 4 -3 9?•8 Feet 9443 Feet <br /> VII. TANK CAPACITY Site <br /> i in allons Total #of Prefab. Fiber- Exp . <br /> INFORMATION New istin Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App. <br /> strutted <br /> Tanks Tanks <br /> Septic Tank orHoldin Tank DO 500 Nf Serrs <br /> Lift Pum Tank1Si hon Chamber 060 000 Li�K ✓' <br /> X 11 <br /> VIII. RESPONSIBILITY STATEMENT /,000 y 6j2EA156772,4O W,e5crr5 Ctrxa�fe <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: oS ps) Mf9MPRSW No.: Tiluaine"_n Phone Number: <br /> cwt J F w - 5119'3 -71S 635- 75rS' <br /> Plum 's AddrUP <br /> ess(Street,City, ate,Zip Coder <br /> ? o , 13 x 71 oo'lev W 1 5 01 <br /> IX. CO NTY/DEPARTMENT USE ONLY <br /> Disapproved Sanitary Permit Fee(Includes Groundwater Date ss Issui g gent Sign a(No Stamps) <br /> roherge Fee) L _ '/n�� <br /> Approved ❑ Owner Given Initial \ �(/ /(/ <br /> A ve Determination �- <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,Owner,Plumber <br />