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DILWR SANITARY PERMIT APPLICATION <br /> In accord with ILHR 83.05,Wis.Adm.Code COUNTY <br /> = r <br /> STATE SANITA Y PERMIT#d j(j J7 <br /> 1i <br /> –Attach complete plans(to he county copy only)for the system,on paper not less than ❑ �� v I <br /> 8'%x 11 inches in size. C eck If revs on to previous application <br /> –See reverse side for instri ictions for Completing this application. STATE PLAN 1.0.NUMBER <br /> 1. APPLICANT INFORMATI DN–PLEASE PRINT ALL INFORMATION. <br /> PROPERTY OWNER PROPERTY LOCATION //aa _ <br /> E L '/4 '/4, S ID T v, N, R IS E( <br /> PROPER WNER'S MAILING DRESS LOT.# BLOCK# <br /> 0 - z L)a <br /> CITY,STATE ZIP CODE PHONE NUMBER SUBDIVIS ON NA E OR CSM NUMBER <br /> e SL . Woso 1( <br /> It. TYPE OF BUILDING: (C eck one) ❑State Owned VILLAGE NE REST ROAD <br /> ❑ Public <br /> l or, Fam.Dwellings of bedrooms— WicG <br /> Etz- <br /> III. BUILDING USE: (If buil(Ing type is public,check all that apply) �� <br /> 1 ElApt/Condo v �V <br /> 2 ❑ Assembly Hall 6 EI Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility <br /> 3 ❑ Campground 7 El 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: (CheDk only one in line A. Check line B if applicable) <br /> A) 1. New 2. D Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5.ElRepair of an <br /> System System Tank Only Existing System Existing System <br /> B) ❑ A Sanitary Permil was previously issued. Permit# — Date Issued <br /> V. TYPE OF SYSTEM: (Ch)ck only one) <br /> Non-Pressurized Distribl.tion Pressurized Distribution Experimental Other <br /> 11 ;�6eepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank <br /> 1 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.A13SORP.AREA 3.ABSORP.AREA 4. LOADING RATE 5. PERC.RATE 6. SYSTEM ELEV. 7. FINAL GRADE <br /> RE IRED(sq.ft.) PROP BED(sq.ft.) (Gals/day/sq.ft.) (Min./inch) q ELE ATION <br /> �, 1 Feet Feet <br /> VII. TANK CAPACITYin allons Total Site <br /> INFORMATION #of Prefab. Fiber- Exper. <br /> New istin Gallons Tanks Manufacturer's Name ccncret Con- Steel glass Plastic App <br /> anks Tanks strutted <br /> Septic Tank or Holdina Tank Jq I I — <br /> Litt Pump Tank/Siphon Chamber <br /> VIII. RESPONSIBILITY STA EMENT <br /> I,the undersigned,assume rE sponsibility for installation of the onsite sewage system shown on the attached plans. <br /> Plumber's Name(Print): Plumber's Signature: Stamps) MP/MPRSW No.: Business Phone Number: <br /> Z S <br /> lu bar's AcTdread(Sliest,City, ate,Zip Code): <br /> ' "Z 0 S Lpj <br /> IX. OUNTYIDE PARTMEN USE ONLY <br /> ❑ DiasDDrove Sanitary Permit Fee(Includes Groundwater Date ssue Is um Agent Sig ure(No Stamps) <br /> Approved ❑ Owner Give Initial (�]� Surcharge Feel <br /> A v D rmin I I�"'� _14 <br /> X. CONDITIONS OF APPR VAL/REASONS FOR DISAPPROVAL: <br /> SBD-8398(formerly Plb-67)(R.11/ ) DISTRIBUTION: Original to County,One Copy To:Safety&Buildings Division,Owner,Plumber <br />