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DILH i SANITARY PERMIT APPLICATION <br /> In accord with ILHR 83.05,Wis.Adm.Code COUNTY,✓? <br /> STATES ITARY P 7MIT#) f— <br /> J 'L <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than <br /> 8'%x 11 inches in size. ❑ Check if revision torevious 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 1. / PROPERTY LOCATION <br /> PQj - z L r '/4 ''/4, S T , N, R E(or <br /> PROPERTY OWNER���NG ADORE � LO_#J� . Lo�S q-� BLOCK# <br /> CITY,STATE ZIP CODE n PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER <br /> It. TYPE OF BUILDING: (Check one) CITY NEAREST ROAD <br /> State owned VILLAGE u / 15,4 <br /> ❑ Publicor 2 Fam. Dwelling-#of bedrooms A L Axnu MULHR(b) <br /> III. BUILDING USE: (If building type is public,check all that apply) /„ - /�/_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 ❑ RestauranVBar/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) 1.0 New 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5.❑ Repair of an <br /> ystem 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-P essurized Distribution Pressurized Distribution Experimental Other <br /> 11 Seepage Bed 21 El Mound 30 EJ 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 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) I ELEVATION <br /> 1 3 ^C^ Feet I Feet <br /> VII. TANK CAPACITY Site <br /> in allons Total III Of Prefab. Fiber- Exper. <br /> INFORMATION New !sting Gallons Tanks Manufacturer's Name Concrete Con- Steel glass <br /> Plastic App <br /> Tanks Tanks structed <br /> Septic Tank or Holdina Tank 7.5-01 Z 7. API, C <br /> Litt 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 /> Plymbef'a Name(Print): Pluature:( 'o Stamps) MP/MPRSW No.: Business Phone Number: <br /> lgxm/-/ ✓ f - zL� C�'7� 7/ <br /> PI ber's A dress Street,City,State,Zip Code): <br /> 19. "COUNTY/DEPARTMENT USE ONLY <br /> Disapproved rsanitary Permit Fee(SurchesGroun water Date IssuedZing gent Signature oStamps) <br /> pproved ❑ Owner Given Initial ,`}1�. �,y*' <br /> Adverse Determination � " Us' ' -Lr I I— <br /> X. <br /> —X. CONDITIONS OF APPROVALIREASONS FOR DISAPPROVAL: <br /> SBD-6398(formerly Plb67)(R.11/98) DISTRIBUTION: Original to County,One Copy To:Safely 8 Buildings Division,Owner,Plumber <br />