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�DILHR SANITARY PERMIT APPLICATION COUNTY <br /> In accord with ILHR 83.05,Wis.Adm.Code <br /> .e.,...�•�.,�,�� STATE SANITARY PERMIT# - <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than ❑ I/I' <br /> 8%X 11 Inches In size. k if reviei 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 /> D19 t N '/a 5W'/a,S T� , N, R LS E (or <br /> PROPERTY OWNER'S MAILING ADDRESS LOT# BLOCK# <br /> SERENO CT- <br /> CITY,STATE `` '' ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER � �i /�V <br /> N C eV <br /> It. TYPE OF BUILDING: (Check one) State Owned VILLAGE W CITY '�` NE EST RO D <br /> MIN❑ �' l <br /> ❑ Public 1 or 2 Fam. Dwelling-#of bedrooms L Ax R( ) 1 <br /> 111. BUILDING USE: (If building type is public,check all that apply) <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. ❑ Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5.❑ Repair of an <br /> X// __ 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 ElMound 30 ❑ Specify Type 41 ❑ Holding Tank <br /> 1 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 /> st) _Lo 20 d -oz- I S• 0 Feet 9S D Feet <br /> VII. TANK CAPACITY Site <br /> in allons Total #of Prefab. Fiber- Exper. <br /> INFORMATION New xistin Gallons of Manufacturer's Name oncret Con- Steel glass Plastic App <br /> Tanks Tanks strutted <br /> Septic Tank or Holding Tank — (O <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 /> Plumber's Name(Print): Plumber's Signature:(No Stamps) MP/MPRSW No.: Business Phone Number: <br /> I C R c ; �. 3126 71 S �'fD6� `/�sl <br /> lumber's Adtlress(Street,City,State,Zip Code): <br /> `7 w S WE05TffZ ( • _gq$ <br /> IX. COUNTYIDEPARTM NT USE ONLY <br /> Lj Disapproved Sanitary Permit Fee(Includes Groundwater Date Issued Issuing Agent Signature(No Stamps) <br /> Surcharge Fee) <br /> PProvetl ❑ Owner Given Initial <9 /�� 0c) <br /> Adverse D rmin tion .—u <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(formerly Plb67)(R.11/99) DISTRIBUTION: Original to County,One Copy To:Safety&Buildings Division,Owner,Plumber <br />