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� DILHR SANITARY PERMIT APPLICATION COUN�✓� <br /> In accord with ILHR 83.05,Wis.Adm.Code 1 <br /> STATE SANITARYERMIT# I3I(�0'� <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than El (W-4-7S7)8'%x 11 inches in size. dlieck it revisisn 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. SSq'- c>101-73 <br /> PROPERTY OWNER PROPERTY LOCATION <br /> Gem -8 q,- ' d Q/p4/btj'/4, S 3( T , N, R 1614( W <br /> PROPERTY OWrER'S UAILING A�RESS LOT# "4— LOT �3 BLOCK# ' /� <br /> CITY,STrTTE 1py,/` ZIP CC1ODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER /" <br /> •e IGj F� ` •STe�9 <br /> It. TYPE OF BUILDING: (Check one) CIN NEAREST ROAD <br /> ����,{{ ❑ State Owned VILLAGE:4PAN PFQ� @"t/ <br /> Q rS Z Q <br /> ❑ Public N 1 or 2 Fam. Dwelling-#of bedrooms PARCEL NUMBER( <br /> III. BUILDING USE: (If building type is public,check all that apply) Ca& 4336- 0j-JM <br /> 1 ❑ ApVCondo <br /> 2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility <br /> 3 ❑ Campground 7 ❑ Merchandise: Sales/Repairs 11 ❑ RestauranVBar/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 F Mound 30 ❑ Specify Type 41 ❑ 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 PERDAY 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 /> 3c to 25- 25­ .2 �o I ' /o /. . 'Z Peet 5;�F /QFeet <br /> VII. TANK CAPACITY Site <br /> in allons Total #of Prefab. Fiber- Exper. <br /> INFORMATION New istin Gallons Tanks Manufacturer's Name oncrete Con- Steel glass Plastic App <br /> Tanks Tanks strutted <br /> Septic Tank or Holdin Tank l�Lift <br /> - <br /> Lift Pum Tank/Siphon Chamber Z; <br /> VIII. RESPONSIBILITY STATEMENT <br /> I,the undersigned,assume responsibility for installation of the onsite sewage system shown on the attached plans. <br /> Plum w's Name(Print): PI er's i ature:(N tamp ) MP/MPRSW No.: Business Phone Number: <br /> e J-e•-cC-(' �y _11 <br /> =7 d o 5 /3 X66- �� <br /> Plumber's Address(Street,City, tate,Zip Code): <br /> L.4A4_�4j - � <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved Sanitary Permit Fee(Includes Groundwater [Date Issued Issuing Agent Signature(NoStamps) <br /> ��0 Surcharge Fee) E <br /> Approved F-1 Owner Given Initial -� C(,(�) <br /> Adverse Det rmi tl n ° <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-8398(formerly Plb-67)(R.11188) DISTRIBUTION: Original to County,One Copy To:Safety&Buildings Division,Owner,Plumber <br />