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DILHR SANITARY PERMIT APPLICATION <br /> In accord with ILHR 83.05,Wis.Adm.Code COUNTY&rnzte— <br /> �• Y� STATE SANITARY PNM IT# <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than �,yf��I7 oVil / <br /> 8%x 11 inches in size. 1:1Chi//ck/levislont revious 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 LOC TION <br /> a Y Ya,S T N, R E (or) <br /> PR ERTYOWNER'SAILING ADDRESS OT# BLOCK! <br /> CITY,STATE ZIPCODE PHONE NUMBER S <br /> E L.. 2. O <br /> I1. TYPE OF BUILDING: (Check one) ❑State Owned VILLAGE C.1 LJ CITY NE R A7 oAC� <br /> ❑ Public 1 or 2 Fam. Dwelling-#of bedrooms M R( ) 1'I N <br /> 111. BUILDINGUSE: (If building type is public,check all that apply) 013 - <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. T^Y�P/E OF PERMIT: (Check only one in line A. Check line B if applicable) <br /> A) 1. KJ New 2. El Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5.El 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 [-1Mound 30 ❑ Specify Type 41 ❑ Holding Tank <br /> 12 1ASeepage 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 D71 2SORP.AREA 3.ABSORP.AREA 4. LOADING RATE 5. PERC.RATE 6. SYSTEM ELEV. 7. FINAL GRADE <br /> RE U (ESD(sq.ft.) PROPOSED(sq.ft.) (Gals/day/sq.ft.) (Min./inch) E EVATION <br /> O C) e ((7-L 3 113. 5 Feet *' S Feet <br /> CAPACITY <br /> VII. TANK Site <br /> in gallons Total #of Prefab. Fiber- Expp. <br /> INFORMATION New istin Gallons Tanks Manufacturer's Name oncret Con- Steel glass Plastic App <br /> Tanks Tanks strutted <br /> Septic Tank or Holding Tank <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 tamps) MPIMPRSW No.: Business Phone Number: <br /> ICw 3 ZG !S blob' /S <br /> Plumber's Address(Street,City,State,Zip Code): <br /> 276 o Nva 35 WaSTV, W1 , S $ <br /> IX COUNTY/DEPARTMENT USE ONLY <br /> Disapproved Sanitary Permit Fee(Includes Groundwater Date Issuing Agenl Si lure <br /> Approved to <br /> ❑ Owner Given Initial y�,J{. Surcharge Fee) •r/1 <br /> A v Determination <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(formerly Pltr87)(R.11/88) DISTRIBUTION: Original to County,One Copy To:Safety&Buildings Division,Owner,Plumber <br />