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DILHR SANITARY PERMIT APPLICATION <br /> In accord with ILHR 83.05,Wis.Adm.Code COUNTY <br /> (Zn1 c rF <br /> STATE SANI7AHYMIT#13 . 7 <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than IR/ec t <br /> 8%x 11 inches in size. ❑ c kifrevisi o 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 /> 9/ C(� '/a SC��'s,S T N, R Ap E (or <br /> PROPERTY WNER'SM ILING ADDRESS LOT# BLOCK# <br /> CI ,STATE ZIP CODE PHONE NUM ER SUBDIVISION NAME OR CSM NUMBER <br /> II. TYPE OF BUILDING: (Check one) ❑ State Owned VILLAGE NE EST RO D <br /> ❑ Public RT, or 2 Fam.Dwelling-#of bedrooms R L ERO —7 <br /> 111. BUILDING USE: (If building type is public,check all that apply) <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. TYrPPE(OF PERMIT: (Check only one in line A. Check line Bit applicable) <br /> A) 1. Ldl New 2. El Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5.El 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 41Holding Tank <br /> 12 ❑ Seepage Trench 22 1-1In-Ground42 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 13.ABSORP.AREA 14. LOADING RATE 15. PERC.RATE 16. SYSTEM ELEV. 17. FINAL GRADE <br /> Q REOUIRED(sq.ft.) PROPOSED(sq.ft.) (Gals/day/sq.ft.) (Mi ./inch) ELEVATION <br /> /v ?4� Feet Feet <br /> CAPACITY <br /> VII. TANK 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 Tanks strutted <br /> Septic Tank or Holdin Tank <br /> Litt Pum Tank/Siphon 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:( Stamps) MP/MPRSW No.: Business Phone Number: <br /> 3 / s 3�9 <br /> Plumber's Address(Street,City,State,Zip ode): <br /> eh� � l chi <br /> IX COUNTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved Sanitary Permit Fee(Includes Groundwater a e ssu Issuing Agent Signature(No Stamps) <br /> Approved ❑ Owner Given Initial `oy �.00Surcharge Fee) <br /> Adv 'n )US <br /> Determination ...J /I <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-8398(formerly Plb-67)(R.11/88) DISTRIBUTION: Original to County,One Copy To:Safety 8 Buildings Division,Owner,Plumber <br />