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DILH I SANITARY PERMIT APPLICATION COUNTY <br /> In accord with ILHR 83.05,Wis.Adm.Code u�r(� <br /> STATESANITARY�PERMIT#'�4Y rf <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than /lgq_,j <br /> 8'%x 11 inches in size. ❑ Check if revisn 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 OWNER PROPERTY LOCATION <br /> oV, o r �� Ir Sw '/4Sir/4,s 3 � TV1, N, R �6 E (o )W <br /> PROPERTY OWNER'S MAILING ADDRESS LOT# BLOCK <br /> `7 / 814 <br /> o /r C N B Lv <br /> CCInITY,STATE L. ZIPCODE PHONE NUMBER SUBDIVISI N NAME OR CSM NUMBER <br /> II. TYPE OF BUILDING: (Check one) CITY NEAREST R(7 D <br /> l�(� ❑State Owned VILLAGE IN-S.!' CCCnot <br /> ❑ Public LTJ 1 or 2 Fam. Dwelling-#of bedrooms� EL A S-Rlsl <br /> 111. BUILDING USE: (If building type is public,check all that apply) �,�/ _/j (✓ /�'"� <br /> 1 ❑ Apt/Condo <br /> 2 ❑ Assembly Hall 6 ElMedical 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 /> 11 Seepage 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 PERDAY 2.ABSORP.AREA 3.ABSORP.AREA 4. LOADING RATE 5. PERC.RATE 6. SYSTEM ELEV. 7. FINAL GRADE <br /> REQUIRED(sq.ft.) PROPOSED(sq.ft.) (Gals/day/sq.ft.) (Min. c,+/inch) ELEVATION <br /> E) 4110 Y3 . 69 / 1-� 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 /> Se tic Tank or Holdino Tank <br /> Litt 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:(N Stamps) MP/MPRSW No.: Business Phone Number: <br /> R,3 , t ' F /F' s C//—T 7 <br /> Plumber's Aggdress(Street,City,State,Zip Code): <br /> e (bS_T;r— w i S <br /> IX. COUNTYIDEPARTMENT USE ONLY <br /> Diaapproved San tary Permit Fee tlncludes Groundwater e e ssue Issuing Agent Signature(No Stamps) <br /> Surcharge Fee) <br /> Approved ❑ Owner Given Initial 'C�ls C57� /"7_ I7_ <br /> AdverseDtr i in - l �L� ! / <br /> X. CONDITIONS OF APPROVALIREASONS FOR DISAPPROVAL: <br /> SBD-6398(formerly Plb-67)(R.11/88) DISTRIBUTION: Original to County,One Copy To:Safety&Buildings Division,Owner,Plumber <br />