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DILHR SANITARY PERMIT APPLICATION <br /> In accord with ILHR 83.05,Wis.Adm. Code COUNTY nn <br /> C �n <br /> STATE SANITARY�ERMIT#/.�50 <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than (P/O;Y>/) r] <br /> 8'b x 11 Inches in size. ❑ Check If revislbn 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 PROPERTY LOCATION <br /> 0 X f> NW'/4A4' P'/4, S T (%, N, R S E (or <br /> PROPERTY OWNER'S MAILING ADDRESS LOT# BLOCK# <br /> 370 wisiis l.7iE, ,<"EL�7r�� ,�-f 0% �- <br /> CITY,STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBE <br /> wr` sy�3�r �mvG©r lAa a « ` <br /> It. TYPE OF BUILDING: (Check one) ❑ State Owned VILLAGE ITY AREST ROAD _ <br /> ❑ Public 1 or 2 Fam. Dwellin A/ w��i� All;1� li1fE <br /> g-#ofbedrooms Ax NUMBER( ) <br /> III. BUILDING USE: (If building type is public,check all that apply) �— 43 <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. 171 Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5.❑ Repair of an <br /> System ystem Tank Only Existing System /Existing System <br /> B) A Sanitary Permit was previously issued. Permit# 5ro7-37 Date Issued <br /> V. TYPE OF SYSTEM: (Check only one) <br /> NoWressurized Distribution Pressurized Distribution Experimental Other <br /> 11Seepage Bed 21 ❑ Mound 30 ❑ SpecifyType 41 ElHoldingTank <br /> 12Seepage 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 5. PERC.RATE 6. SYSTEM ELEV. 7. FINAL GRADE <br /> REQUIRED(sq.ft.) PROPOSED aq.ft.) (Gals/day/sq. <br /> It.) <br /> (Min./inch) ELEVITION <br /> r �1 <br /> 6 3 90-i Feet 9 _Feet <br /> VII. TANK CAPACITY <br /> in ollons Total Site <br /> INFORMATION III Prefab. Fiber- Exper. <br /> New iatin Gallons Tanks Manufacturer's Name oncrete Con- S I glass Plastic App <br /> Tanks Tanks structed <br /> Septic Tank or Holding Tank �QL7 <br /> Litt Pum Tank/Si hon Cha ber r <br /> Vlll. RESPONSIBILITY&TATEMENT <br /> I,the undersigned,assume responsibility for installation of the onsite sewage system shown on the attached plans. <br /> PI er's Name(Print): Plu natu 1( S MP/MPRSW No.: Business Phone Number: <br /> P mber's Address(Street,City,State,Zip Code): <br /> T _ 6ing <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> Disapproved I Sanitary Permit Fee(Includes Groundwater Date esus Is iI Agent (No Stamps) <br /> Approved ❑ Owner Given Initial /'�� surcharge Fee) <br /> A ve D rmin i n <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 />