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DILHR SANITARY PERMIT APPLICATION COUNTY(� <br /> In accord with ILHR 83.05,Wis.Adm.Code 1�u <br /> p� s• �_ STATE SANITARY-PERMIT# <br /> –Attach complete plans(to the county copy only)for the system,on paper not less than <br /> 8%x 11 inches in size. ❑ Check if revisiori 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 OW ER p / ,/ PROPERTY LOCATION <br /> L c e da/C 4 IUE-'h 5i-,1 '/4, S / T `�0, N, R /$- E(or) <br /> PROPERTY OWNER'S MAILING ADDRESS LOT# BLOCK# <br /> D — r 4 r/ �0 �Ov _Lot l A� <br /> CITY,STATE ZIP CODE PHONE NUMBER SUBDIVISIONI NAME OR CSM NUMBER <br /> T <br /> II. TYPE OF BUILDING: (Check one) ❑ State Owned VILLAGE ITY NEAREST RO(/�D / <br /> For- <br /> 14 <br /> r (s �7d <br /> ❑ Public 141 or2Fam. Dwelling–#ofbedrooms °� A Ll AxN ZQV UM1BER( <br /> III. BUILDING USE: (If building type is public,check all that apply) <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. ® 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 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) / ,+ELEVATION <br /> 3 O 410 I 5/3 3L- 3 Feet / Feet <br /> VII. TANK CAPACITY Site <br /> in allons Total #ot 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 Holding Tank �7 c�t) rt L <br /> Lift Pump Tank/Siphon Chamber rt <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 Stamps) MP/MPRSW No.: Business Phone Number: <br /> jC4 Lh/r_ h l�o Iti7 S _ 0 OS ( 71s- ) jp /3 <br /> Plumber's A dress(Street,City,State,Zip Code): <br /> IXj COUNTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved sanitary Permit Fee t ncludes Ground <br /> water Date Issued Issuin ant Signatu is(No Stamps) <br /> eApproved ❑ Owner eSucharge Fee) <br /> Adverse Dtermin tin Vy /&! �� <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br />