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aaaaal <br /> DILHR SANITARY PERMIT APPLICATION <br /> R= <br /> In accord with ILHR 83.05,Wis.Adm. Code COUNTY <br /> rR �qg) <br /> -Attach complete plans(to the county copy only)for the system,on paper not less thanSTATEl/�7 <br /> NITAERMIT# <br /> 8%x 11 inches in size. ❑ Check if revisio 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 OWNER1 PROPERTY LOCATION <br /> `� ju-4 1°ICwPic, 6L-4Z_(0 4, S o?(' T Lj N, R J �5_E (or(B <br /> PROPERTY OWNER'S MAILING ADDRESS LOT# IBLOCK# <br /> � � RD <br /> CITY,STA ' ^1 ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER <br /> 07 <br /> NWW OF' <br /> II. TYPE OF BUI DING: (Check one) ❑State Owned VILLAGE �L✓0 CITY NEAREST ROAD <br /> ❑ Public 1 or 2 Fam. Dwelling-#of bedrooms A L I Ax ( ) El <br /> 111. BUILDING USE: (If building type is public,check all that apply) <br /> (9lZ - 22D —D 2 `moo <br /> 1 ❑ Apt/Condo <br /> 2 ❑ Assembly Hall 6 El 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.,jXLReplacement 3. ❑ Replacement of 4. L1 Reconnection of 5.El Repair of an <br /> System A 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 eepage 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 4. LOADING RATE 15. PERC.RATE 16. SYSTEMELEV. 7. FINAL GRADE <br /> REQUIRED(sq.ft.) PROPOSED(sq.ft.) (Gals/day/sq.ft.) (Min h) ( ELEVATION <br /> 34� _ -/ ,r <br /> I Feet Q8b Feet <br /> VII. TANK CAPACITY Site <br /> in allons Total #of Manufacturer's Name Prefab. Con- Steel Fiber- Plastic Exper. <br /> INFORMATION New istin Gallons Tanks oncret strutted glass App. <br /> Tanks Tanks <br /> Septic Tankor Holding Tank -!D UAC <br /> Lift Pum Tank/Si hon Chamber <br /> VIII. RESPONSIBILITY STATEMENT <br /> I,the undersigned,assume responsibility for installation of the onsite sewage system shown on the attached plans. <br /> PI 's Name(Print): J� Plum :( Sta ps) MP/MPRSW No.: Business Phone Number: <br /> W-3 09 <br /> Plumber's Address(Street,City,State,Zip Code), <br /> 7 3 & D9�i2 5 � 3 0 <br /> IX COUNTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved Sanitary Permit Fee (Includes Groundwater Date Issued Issuing Agent Signature(No Stamps) <br /> Approved E1 Owner Fee) <br /> Owner Given Initial Af'/ e 1,-�—, p�a�7� <br /> Adverse Determination ,�j (J(-,/ o / \,!� 1 man <br /> X. 6ONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(formerly Plb-67)(R.11/89) DISTRIBUTION: Original to County,One Copy To:Safety&Buildings Division,Owner,Plumber <br />