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DILHR SANITARY PERMIT APPLICATION COUNTY <br /> In accord with ILHR 83.05,Wis.Adm.Code <br /> ss than STATE SANITARY P MIT#13a5,;q <br /> -Attach complete plans(to the county copy only)for the system,on paper not le / 7 <br /> 8'%x11inches insize. ❑ ChhCkifyrevlalon prevlouaapplication <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 /> w lU tr r /()W1/4 NW1/4, S 3T�l�, N, R � E ( W <br /> PROPERTY OWNER'S MAILING ADDRESS LOT# BLOCK# <br /> 1 r r <br /> CIN,ST�`TE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER <br /> $ Pa Sl U 67c c< < c T <br /> Li CITY NEAREST ROAD <br /> II. TYPE OF BUILDING: (Check one) ❑ State Owned VILLAGE=OWN 05 <br /> 0 9�� tea Pur�S f <br /> ❑ Public 1 or 2 Fam.Dwelling-#of bedrooms REL AX NU ER( ) <br /> III. BUILDING USE: (If building type is public,check all that apply) ao— 433J7"-— <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. 1�j 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 E 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.RATE 6. SYSTEM ELEV. 7. FINAL GRADE <br /> REQUIRED(sq.ft.) PROPOSED(sq.ft.) (Gals/day/sq.ft.) (Min./inch) EELEVAJ[ON <br /> S U (, / S - �p S -� Feet / 7'� Feet <br /> VII. TANK CAPACITY Site <br /> in allons Total #of Prefab. Fiber- Exper. <br /> INFORMATION New istIn Gallons Tanks Manufacturer's Name Plastic Concrete strutted Con- Steel glass App <br /> Tanks Tanks <br /> Septic Tank or Holdino Tank lKed064 <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 N me(Print): Plumber's Signature:(No Stamps) MP/MPRSW No.: �(us <br /> iness Phone Number: <br /> rrc � �iw1f ® 3 eSfis 4� his <br /> Plumber's Address(Street,Ci State,Zip Code): <br /> L. ,P_ LxJ- 's- rP ? <br /> IX. COUNTYIDEPARTMENT USE ONLY <br /> ❑ Disapproved Sanitary Permit Fae(ISurcnesGrrge oun water ae s-sVu" Iss g gent Signat a oStamps) <br /> Approved ❑ Owner Given Initial I O� �qr� a7y. <br /> AdverseDetermination l OF <br /> X. CONDITIONS OF APPROVAUREASONS FOR DISAPPROVAL: <br /> SBD-6398(formerly Plb-67)(R.11/88) DISTRIBUTION: Original to County,One Copy To:Safety&Buildings Division,Owner,Plumber <br />