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ti DILHR SANITARY PERMIT APPLICATION COUNTY <br /> In accord with ILHR 83.05,Wis.Adm.Code ����. <br /> STATE SANITARY R�RMIT# � <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than <br /> 8'%x 11 inches in size. El if revision4o 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 /> _ J � /)CI/a/ULl-_%, S T (,)N, R E (or W <br /> PROPERTY OWNER'S MAILING ADDRESS LOT# ^ BLOCK# � <br /> CITY,STATE ZIPCODE PHONE NUMBER SUBDIVISION NAME OR C NUMBER <br /> cst 1 ab' , <br /> II. TYPE OF BUILDING: (Check one CITY NEAR ST ROAD / <br /> LJ Owned VILLAGE � �� , Cigl�Lr 1hiAl� <br /> ❑ Public 1 or 2 Fam. Dwelling-#of bedrooms— REL Nu R( ) <br /> III. BUILDING USE: (If building type is public,check all that apply) <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 g ❑ Office/Factory 13 ❑ Other: Specify <br /> IV. TYPE OF PERMIT: (Check only one in line A. Check line B if applicable) <br /> A) 1. LVNew 2. El 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 <br /> Seepage 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 /> REQUIRED(sq.ft.) PROPOSED( ft.) (Gals/day/sq.ft.} (Min./inch) p / ,, ELEVATION <br /> �L('1 G_ •`J� /f-t. ' Feet Feet <br /> VII. TANK APACITY Site <br /> 11 ns Total #ot Prefab. Fiber- Exper <br /> in . <br /> INFORMATION New istin Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App <br /> Tanks Tanks strutted <br /> Septic Tank or Holdina Tank Zt - <br /> Lift Puma,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): Plunature:(No Sta P I MP/MPRSW No.: Business Phone Number: <br /> Plumber's Address(sttrreeet,City,State,Zip Co e): <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> Disapproved I Sanitary Permit Fee(Inciudes Groundwater a ssu Issuing gent Signature(No Stamps) <br /> n� Surcharge Fee) ,` \ y <br /> Approved ❑ Owner Given Initial f(� L",v C(__ t)q � ( 11J m.`tt.� <br /> Adverse Determination <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 />