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DILHR SANITARY PERMIT APPLICATION <br /> COUNTY <br /> In accord with ILHR 63.05,Wis.Adm.Code <br /> STASAy,ITY PER�IT# _.. <br /> —Attach complete plans(to the county copy only)for the system,on paper not less than �� zJ?�cXs'C <br /> 8'fi x 11 inches In size. Check if revision to previous appncation <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 /> �� '/4 Y4,S T N, R E(or W <br /> PROPERTYOWNER'S MAILING ADDRESS LOT# BLOC # <br /> S IN 190D 2 1 D . 13 7 <br /> CITY,STATE ZIP CODE PHONE NUMBER SUBDIV1610N NA E 7CSM NUM ERI �� <br /> f�• 5 2 1' t'- 1 O <br /> Lj CITY NEAF EST ROAD <br /> II. TYPE OF BUILDING: (Check one) LJ State Owned VILLAGE: S U, 8 <br /> 0_ <br /> ❑ Public 1 or 2 Fam.Dwelling—#of bedrooms <br /> III. BUILDING USE: (If building type is public,check all that apply) v—��'� 1 I b <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 ❑ Se ice 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 /> of an <br /> A) 1�SNew ystem 2 ❑ Sytem Replacement 3. ❑Tank Only <br /> of 4. ❑ Reconnection of <br /> Existing System 5 ❑ 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 /> 1117S Seepage Bed 21 El Mound 30 El SpecifyType 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.RATEJ& SYSTEMELEV. 7. FINAL GRADE <br /> REQUIIR7EDD(sq.ft.) PROPOSED <br /> 7(sq.ft.) (Gels/day/sq.ft.) (Min./inch) r�ELEVATION <br /> 30o 7 I �G _7 00 -O Feet VZ.S Feet <br /> CAPACITY Site Fiber- Exper. <br /> VII. TANK in 11 Ina Total #of Manufacturer's Name Prefab. <br /> Con- Steel glass Plastic App. <br /> INFORMATION New Istin Gallons Tanks structed <br /> Tanks Tanks <br /> Se tic Tank or Holding Tank <br /> Lift Pump Tank/Si hon 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): Plumber's Signature:(No tamps) MP/MPRSW No.: Business Phone Number: <br /> Ic ntS Z6 <br /> Plu bar's Address(Scree,City,State,Zip Code: <br /> z 3s W w( 8 <br /> IX. COUNTY/DEPARTMENT USE ONLYIsauin ant ' na ( o mps) <br /> ❑ Disapproved Sanitary Permit Fee(IncludSgo,he Y Feed water ate ssue 9 g <br /> Approved Owner Given initial �\SL S <br /> F-1 <br /> AdverseDeterminaticn <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, wner,Plumber <br />