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DILHR SANITARY PERMIT APPLICATION <br /> In accord with ILHR 83.05,Wis.Adm.Code COUNTY <br /> 1(fin <br /> STATE SANITARYMIT#is <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than `'��//' JJ <br /> 8'%x 11 inches in size. ❑ C kif aiOht 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 /> S S 3 T14 N, R & E (Or OW <br /> PROPERTY OWN R'S MAILING ADDRESS LOT# BLOCK# <br /> CITY,STATE ZIPCODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER, <br /> u4 G/ P ?J4 t V06 ago f? -393 <br /> If. TYPE F BUILDING: (Check one) El State Owned VILLAGE NEAREST ROAD <br /> ❑ Public Ki <br /> or 2 Fam. Dwelling-#of bedrooms PAPIRWRIJ EK(S) <br /> III. BUILDING USE: (If building type is public,check all that apply) �53 4-. OS--b <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: (Checkonlyone in line A. Check line B if applicable) <br /> A) 1. El New 2. J�Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5.L1Repair 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 �SeepageBed 21 ❑ Mound 30 L1 Specify Type 41 EJ HoldingTank <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 3.ABSORP.AREA 14. LOADING RATE 15. PERC.RATE 16. SYSTEM ELEV. 17. FINAL GRADE <br /> 3 REQUIRED(sq.ft.) PROPOSED(sq.ft.) I (Gals/day/sq.ft.) (Min <br /> ./i ch) / a ELEVATION <br /> aV •�pQ �t� rp Feet q3- 5,5 Feet <br /> VII. TANK CAPACITY Site <br /> in allons Total #of Prefab. Fiber- Exper. <br /> INFORMATION New istin Gallons Tanks Manufacturer's Name oncrete Con- Steel glass Plastic App <br /> Tanks Tanks strutted <br /> Septic Tank or HoldinTank . C <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): Plum I ure:(No tamps) MP/MPRSW No.: Business Phone Number: <br /> ons � ' of � 3072 ?t� 24 3So <br /> Plumber's Address(Street,city,State,Zip Code): <br /> ,?T r5 V70 <br /> IX COUNTY/DEPARTMENT USE ONLY <br /> Disapproved Sanitary Pe it Fee(Includes Groundwater a e Issued Issuing Age Signa re N St <br /> Approved dT Surcharge Fee) /� Q Q, '�/r <br /> OwnereDetermination <br /> etermi al _ 10�. u <br /> Adverse D t r in i n <br /> X. CONDITIONS OF APPR VAL/REASONS F0 DISAPPROVAL: <br /> Se- 5-," '� > �i/JT/,7 `j?" es / <br /> SBD-6398(formerly Plb-67)(R.11/88) DISTRIBUTION: Original to County,One Copy To:Safety&Buildings Division,Owner,Plumber <br />