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DILHR SANITARY PERMIT APPLICATION <br /> In accord with ILHR 83.05,Wis.Adm.Code COUNTY— v x 11 inches in size. cBuRrJETr <br /> ���• STATE/S'ANITARY ERMIT#�y.�t. <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than ❑ �153c � <br /> 8'% heck 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. 1S�� x0958 <br /> PROPERTY OWNE PROPERTY LOCATION <br /> '/4 '/4, Sr T , N. R E (Of <br /> PROPE TV O R'S MAI ING ADOR LOT# BLOCK# <br /> 5 _ - <br /> CITY STATE _ ZIP C PE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER <br /> l W�3 rA0 ' <br /> It. TYPE OF BUILDING: (Check one) State Owned <br /> CITY : NEA E T ROAD O <br /> ILLAOE <br /> ❑ Public 1 or 2 Fam. Dwelling-#of bedrooms—3 <br /> A <br /> 111. BUILDING USE: (If building type is public,check all that apply) 8-333 5 -Q5 ' CO <br /> 1 ❑ Apt/Condo <br /> 2 ❑ Assembly Hall 6 1:1 Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility <br /> 3 ❑ Campground 7 [:1 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. Replacement 3. ❑ Replacement of 4. 1:1Reconnection of 5.❑ Repair of an <br /> System IzSystem 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 41Holding Tank <br /> 12 ElSeepage 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 5. PERC.RATE 6. SYSTEM ELEV. 7. FINAL GRADE <br /> REQUIRED(sq.ft.) PROPOSED(sq.ft.) (Gals/day/sq.ft.) (Min./inch) ELEVATION <br /> Feet _� Feet <br /> VII. TANK CAPACITY Site <br /> in gallons Total #Of Prefab. Fiber- Exper. <br /> INFORMATION New istin Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App <br /> Tanks Tanks structed <br /> Septic Tank or HoldinTO <br /> Tank / <br /> El El <br /> Lift Pum Tank/Si hon 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/MPRSWNo.: Business Phone Number: <br /> Plumber' Address(Street.City State Zip Cod ): <br /> �r u /1 � <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved Sanitary Permit Fee(Includes ae Feed water Date IssuedIso Agent Sign (No Stamps) <br /> Approved ❑ Owner Given Initial ID&CO 1I_'-]1 <br /> Adverse Determination <br /> �-LI I <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> ��PSS QYiuc fo tid�c�ih ,�s r be nzo v �0 SF <br /> SBD-8398(formerly Plb87)(R.11/88) DISTRIBUTIOIV Original to County,One Copy To:Safetr&Buildings Division,Owner,Plumber <br />