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DlLHR SANITARY PERMIT APPLICATION <br /> In accord with ILHR 83.05,Wis.Adm.Code COUNTY <br /> --• � :Burnam <br /> STATE SANITARY PERMIT#la l S r1U <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than1:1 ((411p)l <br /> 8'%x 11 inches in size. check if revi ion 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. <br /> PROPERTY OWNER -F- PROPERTY LOCATION <br /> 4r !v W%A)U '%, S ,�$ T `l0, N, R /S (or W <br /> PROPERTY OWNER'S MAILING ADDRESS LOT# BLOCK# <br /> cttr Le.t,4 "4 v S /J` <br /> CITY,STATE ZIP CODEPHONE NUMBER SUBDIVISION NAME OR CSM NUMBER <br /> t r wi S Y IF - L -rAcres <br /> II. TYPE OF BUILDING: (Check one) CITY NEAREST ROAD <br /> II BUILDING: ❑State Owned ❑ VILLAGE <br /> ❑ Public L.L�J1or2Fam. Dwellin < R '( ^� <br /> g-#ofbedrooms� PAR EL TAX NU <br /> 111. BUILDING USE: (If building type is public,check all that apply) 1 - 01Vo — �-AJ <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 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 /> 11Seepage Bed 21 ElMound 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 72.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) Q ELELEVATION <br /> O Co/ a— (0 Y S, M? -;> S ! f _' Feet / JFFeet <br /> VII. TANK CAPACITY Site <br /> in allons Total #of Manufacturer's Name Prefab. Con- Steel Fiber- plastic Exper. <br /> INFORMATION New ExistingGallons Tanks Concrete glass App. <br /> Tanks I Tanks strutted <br /> Septic Tank or Holdina Tank <br /> Litt 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): Plum 's Sig ature:(N Stamps) MP/MPRSW No.: Business Phone Number: <br /> Ro rt r- f c 6 � c T 'f 7 <br /> Plumber's AQdress(Street,City.State,Zip Code): <br /> Ic I ,S'cr 3�t <br /> IX. COUNTY/DEPARTMENT U E ONLY <br /> Disapproved I Sanitary Permit Fee(Includes Groundwater Date Issue Is Ing gent Signa(No Stamps) <br /> Approved ❑ Owner Given Initial 14 (pro surcharge Fee) <br /> A v Determination i0s ��� <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(formerly Plb-67)(R.11/98) DISTRIBUTION: Original to County,One Copy To:Safety&Buildings Division,Owner,Plumber <br />