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DILHR SANITARY PERMIT APPLICATION COUNTY <br /> _ n accord with ILHR 83.05,Wis.Adm. Code <br /> �~ STATE SANITARY PERMIT# 12SS� <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than ❑ C1�7 <br /> 8'%x 11 inches in size. Check if revision o previous a plication <br /> -See reverse side for instructions for Completing this application. STATE PLAN I.D.NUMBER <br /> I. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION. 5 3q- ;Loq O 9 <br /> PROPERTY OWNER PROPERTY LOCATION <br /> on ��RYaI_ .1-.E y,�tJ y,, S ZO T4-0, N, R I+ E(or) <br /> PROPERTY OWNER'S MAILING ADDRESS LOT �# BLOCK# <br /> 812.0 3e r�rd #a /f <br /> CITY,STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER n <br /> BI rv, fil 56}31 1 r 3.13 <br /> It. TYPE OF BUILDING: (Check one) CITY NEAREST ROAD <br /> ❑ State Owned VILLAGE: �C p� ORK LHK£ �CL <br /> ❑ Public ®1 or 2 Fam. Dwelling-#of bedrooms? REL NUMB R ) <br /> III. BUILDING USE: (If building type is public,check all that apply) a 8 _ < a o - 05 y,.)D <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 B ❑ 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 ❑ 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 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 /> 3 o O AJIA AJ /1 !ll L,4 IV R /V H Feet I A)1,4. Feet <br /> VII. TANK CAPACITY 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 Tanks structed <br /> Septic Tank or Holdino Tank 2.04,0 <br /> Litt Pum Tank/Siphon Chamber <br /> VIII. RESPONSIBILITY STATEMENT <br /> I,the undersigned,assume responsibility for installation of the o site sewage system shown on the attached plans. <br /> Plumber's Name(Print): Plu ber's Signature:(No mps) MP/MPRSW No.: Business Phone Number: <br /> mew,V% T �ar kSow L".13393 715 5-7 S <br /> Plumber's Address(Stree,City,State,Zip Code): <br /> r-.O. I'JX71 05 OOh !A.)rJ' 'f80/ <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> Lj Disapproved Sanitary Permit Fee(Includes Groundwater Date Issued gent Signa re(No Stamps) <br /> Fee) <br /> Approved ❑ Surcharge <br /> Owner Given Initial \(� �_. -1(J 6 <br /> Adverse rminat on v <br /> X. CONDITIONS OF APPROVALIREASONS FOR DISAPPROVAL: <br /> SBD-6399(formerly Plb-67)(R.11/88) DISTRIBUTION: Original to County,One Copy To:Safety&Buildings Division,Owner,Plumber <br />