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DILHF s SANITARY PERMIT APPLICATION <br /> couNTv <br /> In accord with ILHR 83.05,Wis.Adm.Code S.(ra'E'J / <br /> STATE SANITARY PERMIT#,-b–Attach complete plans(to the county copy only)for the system,on paper not less than ❑ qw � ) <br /> 834 x 11 inches In size. heck if revision 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. a.i u <br /> PROPEIIR__TY--OW ER PROPERTY LOCATION <br /> R OYLE�- Uj i 1 Ker SD--, SU44 S4/%, S ;LG T39, N, R I G E-0r OW <br /> PROPERTY OWNER'S MAILING ADDRESS LOT# BLOCK# <br /> 13 rAc ,� Sr. 10 <br /> CITY,STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR OSM NUMBER <br /> VI1 VV1V\ S� l �PI 7 /O Cut" Lke�. }PinPS <br /> II. TYPE OF BUILDING: (Check one) CITY NEAREST ROAD <br /> ❑ State Owned ❑ VIL1W NLAGE rn e e m D� <br /> ❑ Public ®1 or 2 Fam.Dwellings of bedrooms 3 NUAll 1A DaV/S On V2 . <br /> Ill. BUILDING USE: (if building type is public,check all that apply) �g_Qoas-D�=Bco <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. ElNew 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 12.ABSORP.AREA 13.ABSORP.AREA 14. LOADINGRATE 15. PERC.RATE 6. SYSTEM ELEV. 7. FINAL GRADE <br /> REQUIRED(sq.ft.) PROPOSED(sq.ft.) (Gals/day/sq.ft.) (Min./inch) ELEVATION <br /> LIS I I I Feet Feet <br /> CAPACITY <br /> VII. TANK Site <br /> in allons Total #of Prefab. Fiber- Exper. <br /> INFORMATION New istin Gallons Tanks Manufacturer's Name oncret Con- Steel glass Plastic App <br /> Tanks an strutted <br /> Septic Tank oldinTa W I F <br /> Lift Pump Tank/Siphon Chamber <br /> VIII. RESPONSIBILITY STATEMENT <br /> I,the undersigned,assume responsibility for in tallation of the onsite sewage system shown on the attached plans. <br /> Plumber's Name(Print): Plumb is Signature:( o S ps) MP/MPRSW No.: Business Phone Number: <br /> ti�ls b-P F- WIh646e <br /> Plumber's Addreaa6t"1 reet.Ci , Zip Code): �r <br /> COUNTY/DEPARTMENTQUSE ONLY <br /> Disapproved Sa ary Permit Fee(InurchareI:eel eter aesaue IaauingA nt Sl No mps) <br /> Approved ❑ Owner Given Initial 1�5� F�s."roharge Fee) /} DIY �n <br /> Adverse Determination t w <br /> 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 />