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DILHR SANITARY PERMIT APPLICATION <br /> In accord with ILHR 83.05,Wis.Adm.Code COUNTY <br /> o - &✓IZ c <br /> STATE§A NITARY�RMIT#/574{:3,6 <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than C /gam <br /> 8%x 11 inches in size. ❑ Check 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. <br /> PROPERTY OWNER PROPERTY LOCATION <br /> h '/a 4l'/a,S / T N. R E (or <br /> PROPERTY OWNER S MAILING ADDRESS LOT# BLOCK# <br /> 'q ZVOQ Lh til <br /> CITU,S TE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR C M NUMBER <br /> — 11 <br /> II. TYPE OF BUILDING: (Check one CITY I g/pE NEAREST ROAD <br /> I�� ) State Owned VILLAGE <br /> ❑ Public N1or2Fam. Dwelling-#ofbedrooms- � A L A NU <br /> III. BUILDING USE: (If building type is public,check all that apply) J U <br /> 1 ElApt/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 Bit applicable) <br /> A) 1.Y New 2. ❑ Replacement 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 Pressurized Distribution Experimental Other <br /> 11 ❑ Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 Q oldingTank <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. 17. FINAL GRADE <br /> &v REQUIRED(sq.ft.) PROPOSED(sq.ft.) (Gals/day/sq.ft.) (Min./inch) ELEVATION <br /> 1 ^ 1Feet Feet <br /> VII. TANK CAPACITY Site <br /> in allons Total #of Prefab. Fiber- Exper. <br /> INFORMATION New istin Gallons Tanks Manufacturer's Name oncrete Con- Steel glass Plastic App <br /> Tanks Tanks strutted <br /> Se tic Tankor Holding!'-n, <br /> Lift Pump Tank/SI hon Chamber i r17 <br /> VIII. RESPONSIBILITY STATEMENT <br /> [,the undersigned,assume responsibility for installation of the onsite sewage system shown on the attached plans. <br /> Plumber's N e(Print): / Plumber's 'gnature:(No Stamps) MP/MPRSW No.: Business Phone Numbsr: <br /> Plumber's dress(Street,City,State Code): <br /> S o <br /> IX. COUNTY EPART ENT USE ONLY <br /> ❑ Disapproved Sanitary Permit Fee(Includes Groundwater ee ssue IssuingA nt natur (No <br /> Approved ❑ Owner Given Initial �O�' Surcharge Fee) 1_7 _ <br /> Adverse Determination —� ' OT-) - <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&Buildings Division,Owner,Plumber <br />