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17—DILHR SANITARY PERMIT APPLICATION COUNTY,— <br /> In accord with ILHR 83.05,Wis.Adm.Code r <br /> M« STATE SSANITARY.p\ERMIT#�a1 R 35$ <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than � J <br /> 8'%x 11 inches in size. ch k If revisioA 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. <br /> PR9Pf RTY WNER PROPERTY LOCATION <br /> '/4 '/4,S 7 T �, N, R E(or <br /> PROPERTY OWNER'S MAI NG ADDRESSLOT# BLOCK# <br /> ><. e . — <br /> CITY,STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER <br /> hreaa&, It <br /> IL TYPE OF BUILDING: (Check one) Cin" NEAREST ROAD <br /> r.-ri ❑ State Owned VILLAGE' M I o-e�V2 <br /> ❑ Public PJ 1 or 2 Fam. Dwelling-#of bedrooms PARCEL TAX N MBER( <br /> III. BUILDING USE: (If building type is public,check all that apply) .-5a�- 6 -530 <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. r" 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 <br /> 1-Pressurized Distribution Pressurized Distribution Experimental Other <br /> 11 IC+,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 DAY 2.ABSORP.AREA 3.ABSORP.AREA 4. LOADING RATE 5. PERC.RATE 6. SYSTEM ELEV. 7. FINAL GRADE <br /> ��11//�� REQUIRED(sq.ft.) <br /> PROPOSED(sq.ft.) (Gals/day/sq.ft.) (Min./inch) _ �/ ELEVpAT-ION <br /> 3C.C.� 40 �� • ? Feet •C� Feet <br /> VII. TANK CAPACITY Site <br /> in galions Total #of Prefab. Fiber- Exper. <br /> INFORMATION New <br /> is <br /> Gallons Tanks Manufacturer's Name ConcreteCon- Steel glass Plastic App <br /> Tanks Tanks strutted <br /> Septic Tank or Holdin Tank () <br /> Lift Pump Tank/Siphon Chamber - <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): Plumber's Signatur .(No Sta ps MP/MPRSWNo.: Business Phone Number: <br /> s ,, ) 330/ <br /> Plufm/per's Address(street,City,state, <br /> /77pip�Coode), <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> Ej Disapproved Sanitary Permit Fee(includes Groundwater Date Issued Issuing Agent Signature(No Stamps) <br /> Surcharge Fee) s <br /> Approved ❑ Owner AdverseGivDini n l_etermiin `1 I� 00 ��. <br /> lJ J <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(formerly Plb67)(R.11/88) DISTRIBUTION: Original to County,One Copy To:Safety&Buildings Division,Owner,Plumber <br />