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DILHR SANITARY PERMIT APPLICATION COUNTY <br /> _ In accord with ILHR 83.05,Wis.Adm. Code <br /> �.,.. s• �- STATE SANITA PERMIT# �5�7 <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than 1:181/2x 11 Inches In size. check if re on to previous application <br /> -See reverse side for instructions for Completing this application. STATE PLAN I.D.NUMBER <br /> 1. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION. G � — <br /> PROPERTY OWNER P PERTY L ATION <br /> * AGER V(LLAGL ? /a,S T N, R E(or W <br /> PROPER OWNER'S MAILING ADDRESS LOT# BLOCK# <br /> "25S51 6U<61Z(-_ EV- <br /> CITY,STATE ZIP CODE PHONE NUMBER Aim <br /> N NAME CSM UMBER <br /> bAfs t)R W( . S X11.5 - 1( <br /> It. TYPE OF WILDING: (Check one) Y NEAREST ROADRft PF' <br /> , <br /> ❑ State Owned VILLAGE 5� E G►2E£PJ f,O <br /> Id-1 Public � or 2 Fam.Dwelling-#of bedrooms— PA XNUMB V <br /> Ill. BUILDING USE: (If building type is public,check all that apply) —q) 07— � <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,X Other: Specify MAIr�Tt/f <br /> IV. TYPE OF PERMIT: (Check only one in line A. Check line Bit applicable) ' <br /> A) 1XNew 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 /> 114�1 Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 El 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 PE2.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) p ELEVATION <br /> Z R DAY � 7 <br /> on <br /> so / 2c) . 2_�7 -� 1 .Z . fi Feet �.S ..S Feet <br /> VII. TANK CAPACITY Site <br /> in allons Total lo <br /> Prefab. Fiber- Exper. <br /> INFORMATION New istin Gallons Tanks Manufacturer's Name oncrete Con- Steel glass Plastic App <br /> Tanks Tanks strutted <br /> Se tic Tank or Holdino Tank 100c, Roo I I i k>(Llfi�fz <br /> Lift Pump Tank/Siphon 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 /> I GN 2p NO K/Al3 j <br /> Plumber's Address(Street,City,Stale,Zip Code): <br /> ,Zl1 ?(,ro NL� , LOEBSIiErL- Wi - 5y9�t3 <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved I Sanitary Permit Fee(Includes Groundwater Date Issued Issuing an Ell re(No Stamps) <br /> Approved ❑ Owner Given Initial �}'I o� Surcharge Fee) <br /> Adverse Determin tin �[.➢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 />