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�DILHR SANITARY PERMIT APPLICATION <br /> In accord with ILHR 83.05,Wis.Adm. Code couNTY <br /> r <br /> STATE�ANITAflY OMIT# <br /> —Attach complete plans(to the county copy only)for the system,on paper not less than C <br /> 8'%x 11 inches In size. ❑ Check if revision to previous application <br /> —See reverse side for instructions for completing this application. STATF.pLAN I.D.NUMBER <br /> I. APPLICANT INFORMATION—PLEASE PRINT ALL INFORMATION. �(/i —p� Q 33 <br /> PROPERTY OWNER LPROPERTYIONNick 8 Beck Kuehn 4,S 34 T 39 , N, R 16 E (or)PROPERTY OWNER'S MAILING ADDRESS BLOCK# <br /> 25122 Lakeview Road 5 <br /> CITY,STATE ZIPCODE PHONE NUMBER E OR CSM NUMBER <br /> SiAen, p/I 54872 h Subdivibson <br /> CITYII. TYPE OF BUILDING: (Check one) ❑State Owned 13 CITY NEAREST ROAD <br /> eenon Lakeview Road <br /> ❑ Public ®1 or 2 Fam. Dwelling—#of bedrooms 3 PARCEL TAX NUMBERS) <br /> III. BUILDING USE: (If building type is public,check all that apply) I tL iq'�03— LDo <br /> 1 ElApt/Condo f <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 /> 11 ❑ Seepage Bed 21 ❑ Mound 30 ❑ SpecityType 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 13.ABSORP.AREA 14. LOADINGRATE 5. PERC.RATE 6. SYSTEM ELEV. 17. FINAL GRADE <br /> REQUIRED(sq.ft.) PROPOSED(sq.ft.) I (Gals/day/sq.ft.) (Min./inch) ELEVATION <br /> 450 ------- ------- -------- ------ ------- Feet ----- Feet <br /> VII. TANK CAPACITY Site <br /> in allona Total #of Prefab. Fiber- Exper. <br /> INFORMATION New istin Gallons Tanks Manufacturer's Name oncrete Con- Steel glass Plastic App <br /> Tanks Tanks strutted <br /> Septic Tank or Holdinct Tank <br /> Lift Pum Tank/ i hon Chamber <br /> Vlll. 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 Stamps) MP/MPRSW No.: Business Phone Number: <br /> (Dade Ru{,sho2m [y stag( �i_ 3361 715 349-7286 <br /> Plumber's Address(Street,City,State,Zip Code): <br /> 24702 Lind Road P.U. Box 514 Shen, p/I 54872 <br /> A. OUNTY/DEPARTMENT USE ONLY <br /> ❑ <br /> Disapproved Sanitary Permit Fee(Includes Groundwater Fate IssuedIssuing tsigme( mps) <br /> Approved Surcharge Feel <br /> ❑ Owner Given Initial14 <br /> dt^ ��o O, <br /> AdverseDetermination �1D O _/ <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: 7 _%_/ <br /> SBD-8398(formerly Plb-67)(R.11/88) DISTRIBUTION: Original to County,One Copy To:Safety 8 Buildings Division,Owner,Plumber <br />