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DILHR SANITARY PERMIT APPLICATION <br /> In accord with ILHR 83.05,Wis.Adm.Code COUNTY <br /> �• _ STATE SANITARY PERMIT# ���O <br /> -Attach completeplans(to the county copy only)for the system,on paper not less than ( LS4� <br /> 8%x 11 inches in size. ❑ Check 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. <br /> PR ERTY OWNER PROPERTY LOCATION <br /> '/4 '/4,S 9 T N, R / E (off <br /> P RTY 0 12 'S AILIN AA DRESS LOT# BLOCK# <br /> CITY ST TE m ZIP CODE PHONE NUM ER- SUBDIVISION NAME OR�CSM UMBER <br /> It. TYPE OF BUILDING: (Check one) Li CITY : LJ/ 17 <br /> NEAflES ROAD <br /> ❑State Owned VILLAGE <br /> ElPublic �j1 or 2 Fam. Dwellingof bedrooms R LAX NUM ,l <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/Ear/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. 19Replacement 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 3.ABSORP.AREA 14. LOADING RATE 15. PERC.RATE 16. SYSTEM ELEV. 7. FINAL GRADE <br /> RECUI ED(sq.ft.) PROPOSED(sq.ft.) (Gals/day/sq.ft.) (Min./inch) /� �E7LEVATION <br /> (./ % 7 Feet ICI,:�5 Feet <br /> CAPACITY <br /> VII. TANK Site <br /> in allons Total #of Prefab. Fiber- Exper. <br /> INFORMATION New istin Gallons Tanks Manufacturer's Name oncretCon_e st ucted Steel glass Plastic App <br /> Tanks Tanks <br /> Septic Tank or Holding Tank 7Mc- <br /> Lift Pump 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:(No Stamps) MP/MPRSW No.: Business Phone Number: <br /> Plumber's Address(Street,City,Sts Zip Code): <br /> Ile h <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved Sanitary Permit Fee(Includes Groundwater Date issuedIs in Agent Signa o Stamps) <br /> Surcharge Fee) <br /> pproved E] Owner Given Initial \rV-� 0 <br /> Adverse lJ� lS! .� <br /> CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-8398(formerly Plb87)(R.11/88) DISTRIBUTION: Original to County,One Copy To:Safety&Buildings Division,Owner,Plumber <br />