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DILHR SANITARY PERMIT APPLICATION <br /> In accord with ILHR 83.05,Wis.Adm.Code Buirnott- <br /> -Attach—Attach complete plans(to the county copy only)for the system,on paper not less than STATEMIT#��� <br /> kk�""�'' 3 <br /> �C k <br /> 8%x 11 inches in size. ❑ Ch k 1frevision 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 /> PROPERTY OWNER PROPP)ERTY� ATION <br /> YN V 1/4, S T N, R � � E (or W <br /> PROPER OWNER'S MAILING ADDRESS LOT# BLOCK# <br /> p 11 IVA <br /> CITY,STA E ZIP CODE PHONE NUMBER <br /> OW* Wi- X66- c L <br /> 11. TYPE OF BUILDING: (Check one) CITY NFF��REST ROAD <br /> State Owned VILLAGE D R 6XQ 1JNl� J0 <br /> ❑ Public 1 or 2 Fam. Dwelling--#of bedrooms P A R ffil F Y OF <br /> ( ) / I <br /> 111. BUILDING USE: (If building type is public,check all that apply) —3 ��— bOf a/D <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 8 if applicable) <br /> A) 1. ❑ 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 /> 11Seepage Bed 21 ❑ Mound 30 ElSpecify 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 PERDAY 2.ABSORP.AREA 3.ABSORP.AREA 4. LOADING RATE 5. PERC.RATE 6. SYSTEM ELEV. 7. FINAL GRADE <br /> REQUIRED AREA <br /> ft.) PROPOSED(sq.ft.) (Gals/day/sq.ft.) (Min./inch) ELEVATION <br /> loo o Feet <br /> VII. TANK CAPACITY Site <br /> in gallons Total #OfPrefab. Fiber- Exper. <br /> INFORMATION New istin Gallons Tanks Manufacturer's Name ConcreteCon- Steel glass Plastic App <br /> Tanks Tanks strutted <br /> Septic Tank or HoldingTank <br /> Lift Pum Tank/Si hon 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:(No Stamps) MP/MPRSW No.: rus- <br /> Plumber's <br /> iness Phone Numbs <br /> irg : <br /> p iris 3'1 z6 1(5 16b-"115_7 <br /> Address(Street,City,Stale,Zip Code): <br /> 2 (orj }jw 3S WSL31S12 L 1 - -51SU <br /> IX.f COUNTY/DEPARTMENT USE ONLY <br /> Disapproved Sanitary Permit Fee(Includes Groundwater Date IssuedIssuing Ag nt Sig tura N Stamps) <br /> Approved Surcharge Feel <br /> ❑ Owner I,/ <br /> /0_5� � <br /> Adverse Det rmination —F7 I C� <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 8 Buildings Division,Owner,Plumber <br />