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17—DILHR SANITARY PERMIT APPLICATION COUNTY <br /> In accord with ILHR 83.05,Wis.Adm.Code <br /> • _� STATE SANITARY ERMIT#k6_3�- I <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than C/60 <br /> 8'%x 11 inches in size. ❑ check If revisioif 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. is <br /> PROPERTY OWNER PROPERTY LOCATION <br /> -rerrV S(,tJanst , '/a Ya, S T3R , N, R W <br /> PROPERTYOWNER'S MAILING ADDRESS LOT 11/1 BLOCK# <br /> S3 c)r S"te Y Gov't- LoT S <br /> ITV,ST TE I ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER <br /> 1�1 D 7! 689-283 I-�r i P. 10 <br /> II. TYPE OF LDING: (Check one) CITY 1/ ,{� NEARES ROA <br /> ❑ State Owned 2 VILLAGE W O� 4C I�'P O f �tQ YY V' P <br /> ❑ Public 1 or 2 Fam.Dwelling-#of bedrooms A x NUMBER(5) <br /> 111. BUILDING USE: (If building type is public,check all that apply) c�_ J a7- O' <br /> 1 ❑ Apt/Condo <br /> 2 E] AssemblyHall 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. X 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: 3-7,5- <br /> 1. <br /> S1.GALLONS PER DAY 2.ABSORP.AREA 3.ABSORP.AREA 4. LOADING RATE 5. PER'.RATE 6. SYSTEM ELEV. T FINAL GRADE <br /> �—/� R OUIRED(sq.ft.) PROPOSED(sq.ft.) (Gals/day/sq.ft.) (Min./inch) ELEVATION <br /> d] (/ 3�, 79, 111 per- 1/00,C/ Feet /03,7.-Feet <br /> VII. TANK CAPACITY Site <br /> In allons Total #of Prefab. Fiber- Exper. <br /> INFORMATION New istin Gallons Tanks Manufacturer's Name oncrate Con- Steel glass Plastic App <br /> Tanks Tanks strutted <br /> e tic Tan r Holding Tank twol <br /> Pum Ts Si hon Chamber O <br /> Lj <br /> Vlll. 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 Plu bar's Si ature:( o S ps) MP/MPRSW No.: Business Phone Number: <br /> pY / <br /> P I umber'ss AddrejF(_S_0e_e_,_CitV,State,Zip Code): <br /> 7 '( Jn/�n <br /> W. ) OUNTY/DEPART ENT USE ONLY <br /> ❑ Disapproved Sanitary Permit Fee(Includes Groundwater a e 3suea Issuing Agent Signature(No Stamps) <br /> Surcharge Fee) <br /> Approved <br /> El Owner Given Initial i�(✓• 00 <br /> Adverse 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 />