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DILHR SANITARY PERMIT APPLICATION COUNTY <br /> In accord with ILHR 83.05,Wis.Adm.Code <br /> —_ STATE$$SANITARY RMIT#-)^n� <br /> -Attach complete plans to the county copy only)for the system,on paper not less than ❑ � 75 3� cnJ/ <br /> 8%x 11 inches in size. eckitrevis�on previous application <br /> -See reverse side for instructions for completing this application. STATE PLAN 1.0--NUMBER <br /> I. APPLICANT INFORM TION–PLEASE PRINT ALL INFORMATION. <br /> PROPERTY OWNER PROPERTY LOCATION <br /> 'h '/.,S T N, R 16 E(or <br /> PROPERTY OWNER'S MAILIN 3 ADDRESS LOT# BLOCK# <br /> RL <br /> CITY,STATE ZIP CODE FtIONE NU BER SUBDIVIcR N NAME OR CSM NUMBE <br /> If. TYPE OF BUILDING: Check one) CITY NEAREST ROAD <br /> '��77�� ( State Owned VILLAGE <br /> ❑ Public A�1 Or 2 Fam.Dwelling-#of bedrooms— L L7� <br /> 111. BUILDING USE: (If building type is public,check all that apply) 3 <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 Weplacement 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: ICheck only one) <br /> Non-Pressurized Distribution Pressurized Distribution Experimental Other <br /> 11 Rr 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. LOADING RATE 15. PERC.RATE 16. SYSTEM ELEV. 17. FINAL GRADE <br /> REQUIRED(sq.ft.) PROP SED(sq.ft.) (Gals/day/sq.ft.) (Min./inch) ELEVATION <br /> 30o 19,5•(D Feet � Feet <br /> VII. TANK CAPACITY Site <br /> in allons Total #of Prefab. Fiber- Exper. <br /> INFORMATION New Istin Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App <br /> Tanks I Tanks structed <br /> Septic Tank or Holdin Tank <br /> Lia Pump Tank/Siphon Cham r <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.: Bus. ess Phone Number: <br /> -kiwig 9awd <br /> Plum is Address( treet,CI ,State,Z.p Cod ): <br /> 76b .5'1N5-3 <br /> COUNTY/DEPARTM NT USE ONLY <br /> Disappr Td Sanitary Permit Fee(Includes Groundwater e e asue Issu' gent Signetur o Stamps) <br /> Approved ❑ Owner iven Initial -7� surcharge Fee) <br /> Adverse Determination ' � O� / a <br /> X. dONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(formerly Plb67)(R. 1/88) DISTRIBUTION: Original to County,One Copy To:Safety 8 Buildings Division,Owner,Plumber <br />