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DILHR SANITARY PERMIT APPLICATION <br /> In accord with ILHR 83.05,Wis.Adm. Code COUNTY <br /> &f \ <br /> STATE SANITARY PER T# <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than Q <br /> 8'%x 11 inches in size. ❑ Check if revision 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 /> PROPERTY OWNEROPERTY OCATION L <br /> 0G P '/a %a, S T �, N, R 16 E(orkW <br /> PRO OW ER'S MAI ING ADDRESS LOT# BL K# <br /> TY,S ATE )rl1 <br /> ZIP CODE PON NL B R SUBDI ON AME OR SM NUMBER <br /> lu.6 MK <br /> II. TYPE OF BUILDING: (Check one) ❑ State Owned VILLAGE:�. N REQ ROADOF <br /> n <br /> ❑ Public1 or 2 Fam. Dwelling,#of bedrooms PA L AX NU ) L <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 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. ❑ 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 /> 11Seepage 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 7 2,ABSORP.AREA 3.AS RIP.AREA 14. LOADING RATE 15. PERC.RATE 6. SYSTEM ELEV. 7. FINAL GRADE <br /> REQUIRED(sq.ft.) PROPOSED(sq.ft.) (Gals/day/sq.ft.) (Min./inch) ELEVATION <br /> '30c) o G1 3 915-(p Feet 9 S 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 structed <br /> Septic Tank or Holding Tank <br /> Lift Pump Tank/Siphon 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): Plumber's Signature: o mps) MP/MPRSWNo.: Business Phone Number: <br /> Vol) I 5 <br /> umber's Address Street,City,State,Zip Code): <br /> '1 uJ WEBS'fc2 <br /> IX. COUNTYIDEPARTME T USE ONLY <br /> ❑ Disapproved Sanitary Permit Fee(Includes Groundwater ate Issued I uin gent Signauu 76 Stamps) <br /> Approved ❑ Owner Given Initial ��}m. Surcnarge feel <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-8398(formerly Plb-67)(R.11/88) DISTRIBUTION: Original to County,One Copy To:Safety&Buildings Division,Owner,Plumber <br />