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DtLHR SANITARY PERMIT APPLICATION COUNTY <br /> _ In accord with ILHR 83.05,Wis.Adm. Code L2 <br /> ue�• �w STATES IT/AIR/Y PETR IT#��D�D / <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than `1 IOD J 2 <br /> 8'%x 11 inches in size. ❑ Check d revision to evious 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 /> PROPE TV OWNER JPROPERTY LOCATION ,/^ <br /> :5L /a, S v��p TyvN, R /S E (orPROPERTY�WNER MAILING����rn' S Ov,� of BLOCK# <br /> ccZI��P776 DE PHONE NUMBERSION NAMEIOR Cl3M NUMBER <br /> II. TYPE OF BUILDING: (Check one) NEA EST ROAD <br /> ❑State OwnedAGEJQW OF. <br /> �❑ Public W1 or 2 Fam. Dwelling-#of bedrooWX N ( ) <br /> III. BUILDING USE: (If building type is public,check all that apply) a._ H�a/— 0-c - r7001 ❑ Apt/CondoV <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 Bit 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 13.ABSORP.AREA 14. LOADING RATE 5. PERC.RATE 16. SYSTEM ELEV. 17. FINAL GRADE <br /> �/� REQUIRED(sq.ft.) PROPOSED(P. <br /> ft.) (Gals/day/sq.ft.) (Min./inch) ELEVATION <br /> 3(i(.,/ O Feet Feet <br /> VII. TANK CAPACITY Site <br /> ingallons Total #of IPrefab. Fiber- Exper. <br /> INFORMATION New istin Gallons Tanks Manufacturer's Name onca t Con- Steel glass Plastic App <br /> Tanks Tanks strutted <br /> Septic Tank or HoldinTank <br /> Litt Pum 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:( Sta ) MP/MPRSW No.: Business Phone Number: <br /> Plum er's Address(Street,City,State,Zi Code): <br /> Plum Code), <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved Sanitary Permit Fee(Includes Groundwater Date s e Iss ' g gent Sign (No Stamps) <br /> ,µ, Surcharge Feel <br /> TApproved ❑ Owner Given Initial c}t I h 0^ �/ <br /> Adv Determin i n ^!i V ll <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: v <br /> SBD-M8(formerly Plb-67)F.11/88) DISTRIBUTION: Original to County,One Copy To:Safety 8 Buildings Division,Owner,Plumber <br />