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17—DILHR SANITARY PERMIT APPLICATION <br /> In accord with ILHR 83.05,Wis.Adm.Code cou <br /> STATE SANITARY 77IT#)SG—Attach complete plans(to the county copy only)for the system,on paper not less than / O8%x 11 inches in size. ❑ c eck if revisiorevious application <br /> —See reverse side for Instructions for Completing this application. STATE PLAN I.D.NUMBER <br /> I. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION. S / S <br /> PRO ERTY OWNER PROPERTY LOCATION <br /> Q JAle 1"^, S33 3 T , N, R /I InorA <br /> PROPERTY OWNER'S MAKING ADDRESS LOT# BLOCK# <br /> ©. <br /> CI ST9TE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER <br /> CL h 4 ihn ✓�,�06 6 <br /> II. TYPE OF B ILDING: (Check one) CITY NEAREST ROAD /� <br /> 1��y. ❑State Owned VILLAGE Wer /�Cr &i /e Aoc <br /> ❑ Public 19, or 2 Fam. Dwelling-#of bedrooms PA AX Nu ( ) <br /> 111. 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: (Checkonlyone in line A. Check line B if applicable) <br /> A) 1. <br /> EJ 2. ,t'1 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 JK Holding Tank <br /> 12 El 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 PER2.ABSORP.AREA 13.ABSORP.AREA 14. LOADING RATE 5. PERC.RATE 16. SYSTEM ELEV. 17. FINAL GRADE <br /> REQUIRED(sq.ft.) PROPOSED(sq.ft.) (Gals/day/sq.ft.) (Min./inch) ELEVATION <br /> sDAY 0 Feet Feet <br /> VII. TANK CAPACITY Site <br /> in allona Total #of Prefab. Fiber- Exper. <br /> INFORMATION New xiatin Gallons Tanks Manufacturer's Name oncrete Con- Steel glass Plastic App <br /> Tanks Tanks strutted <br /> Septic Tank or Holding Tankage <br /> ank0 OOQ44' -#,f + <br /> Lift Pump Tank/Siphon 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 /> wulac� eh.lo _ 7 <br /> Plumber's Address(Street,City,Stale,Zip Code): <br /> X. OUNTY/DEPARTMENT USE ONLY <br /> ❑ DisapprovedSanitary Permit Fee(InoludeanaFee)Groundwater ae asue Issuin gent Signature(No Stamps) <br /> Surcrge <br /> Approved ❑ Owner Given Initial (os. g <br /> Adv Determination I colJ <br /> X. 6ONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-8398(formerly Plb-67)(R.11/88) DISTRIBUTION: Original to County,One Copy To:Safety 8 Buildings Division,Owner,Plumber <br />