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V DILHR SANITARY PERMIT APPLICATION <br /> In accord with ILHR 83.05,Wis.Adm.Code COON f) <br /> momoomma_� STATE SANITARY PERMIT# t ZSg� <br /> –Attach complete plans(to the county copy only)for the system,on paper not less than ❑ C(416LD <br /> 8%x 11 Inches In size. Check if revision to previous pplication <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 /> 0 r-- %5W '/a, S 2-3 TL(O, N, R t5 E(o W <br /> PROPERTY94-11L MAILING ADDRESS LOT# 1� BLOC'l <br /> QOt�01b ,'1�`- E G /� Oil <br /> TY,STA E ZIP CODE PHONE UMBER. 1 SUBDIVISION <br /> ��1`LNND UMBER <br /> -211 <br /> BLANE4 MO 4_p-,11. TYPE OF ❑ State Owned O BUILDING: (Check one) CITY NEAREST ROAD <br /> VILLAGE \ (_ UAN <br /> ❑ Public X11 or 2 Fam. Dwelling—#of bedrooms EL VER( ) <br /> Ill. 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 9 ❑ Office/Factory 13 ❑ Other: Specify <br /> IV. TYPE OF PERMIT: (Check only one in line A. Check line B if applicable) <br /> A) IAN a w 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5.❑ Repair of an <br /> ystem 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 /> Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 El 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 PER71 2.ABSORP.AREA 13.ABSORP.AREA 14. LOADINGRATE 5. PERC.RATE 16. SYSTEM ELEV. 17. FINAL GRADE <br /> REQUIRED(sq.ft.) PROPOSED(sq.ft.) (Gals/day/sq.ft.) (Min./inch) 1 ELEVATION <br /> 3©O ' -`�JZ— . �p q-I Feet Feet <br /> VII. TANK CAPACITY Site <br /> in allons Total #of Prefab. Fiber- Exper. <br /> INFORMATION New Istin Gallons Tanks Manufacturer's Name oncret Con- Steel glass Plastic App <br /> Tanks Tanks strutted <br /> Septic Tank or Holdina Tank O \li UP <br /> Lift Pump Tank/Siphon Chamber <br /> VIII. RESPONSIBILITY STATEMENT <br /> 1,the undersigned,assume responsibility for installation of the onsite sewage system shown on the attached plans. <br /> Plumber's Name(Print): I Plumber's Sigpature:IN Stam ) MP/MPRSW No.: Business Phone Number: <br /> T-Doula- Hof1c_1&6 b S� /4 01S7 <br /> P uT-7 r��tre City,State, P Code): � Y`�En W( <br /> S1193 <br /> IX. 'Cl1OOUNTY/DEPART,MV`EN USE ONLY <br /> Disapproved Sanitary Permit Fee(Includes Groundwater <br /> ?� 6 <br /> Issuing Agent Signature N <br /> proved F-1 OwnerGiven '0s"rcherge Fee) Stm <br /> A vereDetermination <br /> termin I n *) <br /> Cj <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-M(formerly Plb-67)R.11/99) DISTRIBUTION: Original to County,One Copy To:Safety&Buildings Division,Owner,Plumber <br />