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DILHR SANITARY PERMIT APPLICATION COUNTY <br /> In accord with ILHR 83.05,Wis.Adm. Code BURN !;'P`2 <br /> Mamma STATE NITARY ERMIT# )SIS'/• <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than �37aI_ <br /> 8'%x 11 inches in size. ❑ cn kit revlalo to previous application <br /> –See reverse side for instructions for completing this application. STATE PLAN I.D.NUMBER <br /> 1. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION. <br /> PROPERTY OWNER PROPERTY LOCATION <br /> ;T7."9HAN )UB-'C '/4 ''/4, S 2y' T 40, N, R 14 W <br /> PROPERTY OWNER'S MAILING ADDRESS LOT# BLOCK# <br /> HC 58 CTY B0):1022 <br /> CITY,STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR C NUMBER <br /> 54801 — Cs•v% Joe I P-31 0y '+ L-a+ w <br /> II. TYPE OF BUILDING: (Check one) CITY NEARS T ROAD _ <br /> ❑ State Owned � VILLAGE • � O <br /> El Public ❑1 or 2 Fam.Dwelling-#of bedrooms 1 PAR AX NUM ( ) <br /> III. BUILDING USE: (If building type is public,check all that apply) 2-cd <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 ❑ 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 7 2.ABSORP.AREA 13.ABSORP.AREA 14. LOADING RATE 5. PERC.RATE 16. SYSTEM ELEV. 17. FINAL GRADE <br /> REQUIRED(sq.ft.) PROPOSED(sq.ft.) (Gals/day/sq.ft.) (Min./inch) ELEVATION <br /> 150 205 205 .73 �. 94.4 Feet 96.2 Feet <br /> VII. TANK CAPACITY 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 /> Se tic Tank orHoldin Tank n 7 0 1 :iI'�:�:. R"a <br /> Lia 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's Signature:(No! W/MPRSW No.: Business Phone Number: <br /> J. RGU ;;r; 3393 715- 35-7482 <br /> Plumber's Address(Street,City,State,Zip Code): <br /> HC ,59 Bo`, /6780 r- "Iiv..:_R, l 54801 <br /> X. OUNTY/DEPARTMENT USE ONLY <br /> Disapproved Tsanitary Permit Fee(Includes Groundwatera e ssu Ise g gent Sign a(No Stamps) <br /> Surcharge Fee) I� <br /> 7-1 <br /> Approved Owner Given InitialIOL,- <br /> A D termi i n AY <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 />