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DILHA SANITARY PERMIT APPLICATION <br /> 17— assm'smil COUNTY <br /> In accord with ILHR 83.05,Wis.Adm.Code <br /> STAXE SANITARY PERMIT# <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than <br /> 1:1 )uvq(d <br /> 8'%X 11 Inches In size. Check If revision to previ s 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 ;SUBDIVISION <br /> ATION <br /> /�CJE �i J ( '/a, S T N, R S E (or)W <br /> PROPERTY OWNER'S MAILING ADDRESS BLOCK IF <br /> CITY,STATE ZIP C DE PHONE NUMBERAME OR CSM NUMBERUILDING: Check one) NEAREST ROAD <br /> +� ( ❑State OWn@djD LS 19 IWP�1❑ Public .WSJ 1 or 2 Fam. Dwelling-#of bedroomsINC7 OF' UMIII. BUILDINGUSE: (If building type is public,check all that a <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 8 if applicable) <br /> A) 1-X 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 12.ABSORP.AREA 3.ABSORP.AREA 4. LOADING RATE 5. PERC.RATE 6. SYSTEM ELEV. 7. FINAL GRADE <br /> REQUIRED(sq.ft.) PROPOSEnD(sq.tt.) (Gals/day/sq.ft.) (Min./inch) ELEVATION <br /> 3clo 4( 32 . (!J 44 3• Feet - Feet <br /> CAPACITY VII. TANK CSite <br /> in allons Total #of Prefab. Fiber- Exper. <br /> INFORMATION New xistin Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App <br /> Tanks Tanks strutted <br /> Septic Tank or Holdin Tank — �.. <br /> Lift Pum Tank/Si hon 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:(No Stamps) MP/MPRSW No.: Business Phone Number: _ <br /> C K 0( `�fo15 <br /> Plumber's Address(Street,City, tate,Zip de): <br /> a <br /> IX. COUNTYIDEPARTMEN USE ONLY <br /> ❑ Disapproved SanitaryPermit Fee(Includes Groundwater Date Issued as n Agent ignat No Stamps) <br /> pproved ❑ Owner Given Initial Surcharge Fee)�\tv�� <br /> AdverseDelerminatio <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,Owner,Plumber <br />