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DILHR SANITARY PERMIT APPLICATION <br /> In accord with ILHR 83.05,Wis.Adm.Code COUNTY <br /> �• �� STATE MTA I P RMIT#' <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than �ctJT <br /> 8'%x 11 inches in size. 1:1 � i on to previous application <br /> -See reverse side for instructions for completing this application. STATE PLAN I.D.NUMBER <br /> 1. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION. <br /> PROPERTY OWNER PROPERTY LOCATION <br /> Q r jtJ E� E '/a EY4,S T N, R E (or W <br /> PROPERTY OWNER'S MAILING ADDRESS LOT# BLOCK# <br /> 8 E Pia o - <br /> CITY,STATE ZIPCODE PHONE NUMBER <br /> CITYEBS . iJi 93 <br /> II. TYPE OF BUILDING: (Check one) El State Owned VILLAGE NEAREST ROCITY <br /> p <br /> - <br /> ❑ Public or 2 Fam.Dwelling-#of bedrooms LNUMBERS)m ?10E F <br /> 1 <br /> III. BUILDING USE: (If building type is public,check all that apply) ocu -43aq- D, <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) 1New 2. ElReplacement 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 9Seepage 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 91 2.ABSORP.AREA 13.ABSORP.AREA 14. LOADING RATE 5. PERC.RATE 16. SYSTEM ELEV. 17. FINAL GRADE <br /> REQUIRED(sq.ft.) I PROPOSED(sq.ft.) (Gals/da /sq.ft.) (Min./inch) Q Q ELEVATION <br /> Q O O o lS� Cp ` z .ZJ Feet Feet <br /> VII. TANK CAPACITYcSite <br /> in allons Total #of Prefab. Fiber- Exper. <br /> INFORMATION New istin Gallons of Manufacturer's Name oncret Con- Steel glass Plastic App <br /> Tanks Tanks structed <br /> Septic Tank or Holdin Tank <br /> Lift Pum Tank/Siphon Chamber <br /> Ll <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:(No Sta ps) MP/MPRSW No.: Business Phone Number: <br /> (�� o s 3'�Z, <br /> Plumber's Address(St eet,city,State,Zip Codd): <br /> 21` w 3S 0EBsreR, W i . SL18 3 <br /> IX. OUNTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved Sanitary Permit Fee(Includes Groundwater Date Issued Issuing Agent na r No St ) <br /> A raved Owner Given Initial fir-Surcharge Fee) �,-/I V' - <br /> DV A v r e Determination 3S 'w <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-8398(formerly Plb87)(R.11/88) DISTRIBUTION: Original to County,One Copy To:Safety&Buildings Division,Owner,Plumber <br />