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DILHR SANITARY PERMIT APPLICATION <br /> In accord with ILHR 83.05,Wis.Adm. Code COUNTY�, . ^ <br /> �• Y'� STATE SANITARYVIERMIT#138c 741 <br /> –Attach complete plans(to the county copy only)for the system,on paper not less thanx 11 inches in size. c❑ (i47,Q <br /> 8'% k If revisiQdto 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 /> I)AQto rt LO -K NF_'/4 SS '/4,S (Z TN, R 15 E (or W <br /> PROPERTY OWNER'S MAILING AD RESS LOT# BLOCK <br /> y 001 13 NA <br /> CITY,STATE Zip PHONE NUMBER SUBDIVISION NA OR CSM NUM ER <br /> 1� q� �' <br /> IS S 35 �c�3 <br /> II. TYPE OF BUILDING: (Check one) ❑State Owned VILLAGE Cl CITY NEAREST ROAD <br /> ll�pII n BER(S) 66Z LAE (ROPP <br /> ❑ Public IAI1or2Fam. Dwelling–#ofbed rooms LTAXNUMBER( ) /^yam <br /> III. 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. 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 El 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 PE7 2.ABSORP.AREA 3.ABSORP.AREA 4. LOADING RATE 5. PERC.RATE 6. SYSTEM ELEV. 7. FINAL GRADE <br /> RE UIRED AREA <br /> ft.) PROPOSED(sq.ft.) (Gals/day/sq.ft.) (Min./inch) ELEVATION <br /> 300 to 413-2— 069 3 94.4 Feet 99,1 Feet <br /> CAPACITY <br /> VII. TANK Site <br /> in allons Total #of Prefab. Fiber- Exper. <br /> INFORMATION New istin Gallons Tanks Manufacturer's Name oncret Con- Steel glass Plastic App <br /> Tanks Tanks strutted <br /> Septic Tank or Holdino Tank 1 q 5Z 1 I <br /> Litt Pump Tank/Siphon Chamber <br /> Vlll. RESPONSIBILITY STATEMENT <br /> 1,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 Stamps) MP/MPRSW No.: Business Phone Number: <br /> 1&7ODE7fCK IIOPK�Ns0-- <br /> Plumber's <br /> ' <br /> Plumbei s Address(Street,City,State,Zip Code): <br /> 1 w 113 <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> r1ty'I ❑ Disapproved Sanitary Permit Fee(Includes Groundwater Date IssuedIss n Agent Sign (No Stamps) <br /> Ld1 Approved ❑ Owner Given Initial Q'} ��, (� aurcharge Fee) I'_^ <br /> /\ ADetermination _F/ W a� <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 />