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DILHR SANITARY PERMIT APPLICATION COUNTY <br /> In accord with ILHR 83.05,Wis.Adm.Code �-- <br /> .e.... STATESANITAR PERMIT#� c534� <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than / X5033 <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. SS°J' <br /> PROPERTY OWNER PROPERTYLOCATION //�� <br /> l l( <br /> W % )%' S T.3y, N, R E (oryQ <br /> PRQPERTYOYyNER'S AILING,yDDRESS LOT# ' BLOCK# <br /> CI/7/C/�STS�ATEN// S/1 ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUM�ER �. <br /> l �r mc/ s��a f es 1 6 a <br /> If. TYPE OF BUILDIN : (Check one) CITY N REST ROAD <br /> ❑State Owned VILLAGE /7� //7 / //Oct <br /> 40 <br /> WN RF <br /> ❑ Publicry 1 or 2 Fam. Dwelling-#of bedrooms QiPARCEL TAX NUM R( ) <br /> 111. BUILDINGUSE: (If building type is public,check all that apply) V�- <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. TYOF PERMIT: (Check only one in line A. Check line B if applicable) <br /> A) 1. New 2. El 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 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 2.ABSORP.AREA 3.ABSORP.AREA 4. LOADING RATE 5. PERC.RATE 6. SYSTEM ELEV. 7. FINAL GRADE <br /> REQUIRED(sq.ft.) PROPOSED(sq.tt.) (Gals/day/sq.ft.) (Min./inch) ELEVATION <br /> Feet --Feet <br /> VII. TANK CAPACITY Site <br /> in alloIts Total #of Prefab. Fiber- Exper. <br /> INFORMATION Manufacturer's Name Con- Steel Plastic <br /> New istin Gallons Tanks oncret strutted glass App. <br /> Tanks Tanks <br /> Septic Tank or Holding Tank LJ <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): Plumber's Signature:(N tamps) MP/MPRSW No.: Business Phone Number: <br /> 14je &3V It <br /> lu ber's A�ddhress(Street,City State,Zi Code): 10, <br /> ,CSX ,c%b� , iRZr <br /> rApproved <br /> NTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved Sanitary Permit Fee(includes Groundwater a esus Is7;111t Signa (No Stamps) <br /> �QG Surcharge Fee) r <br /> ❑ Owner Given Initial J, <br /> A ve D termin tion <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 />