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DILHR SANITARY PERMIT APPLICATION COUNTY r <br /> In accord with ILHR 83.05,Wis.Adm.Code <br /> STATE NITARYP RMIT#ISI '_`( <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than / jS5003 AFF <br /> 8'fi x 11 inches in size. ❑ C k it revisio previous application <br /> -See reverse side for instructions for completing this application. STATE PLAN I.D.NUMBER <br /> 1. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION. — <br /> PROPE TY,VWN R P RTY LOCATION <br /> y Q Y. '/4, S ;7_7, T N, R E (Gr W <br /> P OP O ER'S ADDRE LOT# BLOCK# <br /> RD <br /> CITY,STATE 1 DE PHONE NUMBER �r /J <br /> WI <br /> 11. TYPE OF BUILDING: (Check one) El CITY AREST ROAD <br /> ❑State Owned VILLAGE <br /> ❑ Public X1 or 2 Fam. Dwelling-#of bedrooms— A x u ( ) J <br /> 111. BUILDING USE: (If building type is public,check all that apply) g.33�a—Q - <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,XReplacement 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 Press urized Distribution Experimental Other <br /> 11 ❑ Seepage Bed 21 p�,Mound 30 ❑ Specify Type 41 ElHolding 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 6. SYSTEM EL 7. FINAL GRADE <br /> 3�O REQUIRED sq.ft.) PROPOSED(sq.ft.) (Gals/day/sq.ft.) (Min./inch) ELEVATION <br /> 110) . Z F at L-+ O Feet <br /> VII. TANK CAPACITY Site <br /> in allons Total #of Prefab. Fiber- Expe <br /> INFORMATION New istin Gallons Tanks Manufacturer's Name oncret Con- Steel glass Pias pp <br /> Tanks Tanks strutted <br /> Se tic Tank or Holdin Tank <br /> Lift Pump Tank/Siphon Chamber <br /> VIII. 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): PI be 's Signatur NOS mps) MP/MPRSW No.: Business Phone Number: <br /> V+UN <br /> 0 `I Z 15 b- r <br /> tum rs Ad ress(StreettGty,State,Z Cod ): <br /> Z1-7 <br /> COUNt/r0owner <br /> ATM T USE ONLY <br /> pproved Sanitary Permit Fee(includes Groundwater Date IssuedIssuin Agent Signal re(No Stamps) <br /> surcharge Fee) <br /> pprovGiven Initial .�(� -7�Iero rmin tin `IX <br /> co <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 />