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DILHR SANITARY PERMIT APPLICATION COUNTY In accord with ILHR 83.05,Wis.Adm.Code f OtLA�— <br /> mmmmo <br /> STA SANITARY PrMIT�I� 2S� <br /> –Attach complete plans(to the county copy only)for the system,on paper not less than tl <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 /> PROPE OWNER PROPERTY LOCATION <br /> Ya %, S,5� T� N, R I (orrWD <br /> PROPERTY OWNER/;S MAILI G ADPRE LOT#� BLOCK# <br /> CITYYSTATE /v C/(fin ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NU/B�� <br /> II. TYPE OF BUILDING: (Check one) CI , NEA EST ROAD <br /> ❑ State Owned VILLAGE JC•� � CQl7G <br /> ❑ Public PO 1 or 2 Fam. Dwelling-#of bedrooms 3 'PARCEL AXNUMBERS) <br /> III. 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. N 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 ElMound 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.GAL2.ABSORP.AREA 3.ABSORP.AREA 14. LOADING RATE 5. PERC.RATE 6. SYSTEM ELEV. 7. FINAL GRADE <br /> REQUIRE`D(sq.ft.) PROPOSED(sq.ft.) (Gals/day/sq.ft.) (Min./inch) L VATION <br /> 77 <br /> �7"1 / Feet Feet <br /> VII. TANK CAPACITY Site <br /> in allons Total #of Prefab. Fiber- Exper. <br /> INFORMATION New istin Gallons Tanks Manufacturer's Name c ncrete Con- Steel glass Plastic App <br /> Tanks Tanks atructed <br /> Septic Tank or Holding Tank 1,ew I— � <br /> Lift Pum Tank/Siphon Chamber <br /> Vlll. 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/MPRSWNo.: Business Phone Number: <br /> Qd /� 1 33�/ <br /> Plum is Address(Street,City,State Zip ode): <br /> 7 <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> Disapproved I Sanitary Permit Fee(Includes Groundwater ate Issued Ise ng gent Signt e{No Stamps) <br /> S <br /> A105pproved owner Given Initial r /E urcharge Fee) <br /> Adverse rmin Z3 <br /> X. CONDITIONS OF APPROVALIREASONS FOR DISAPPROVAL: <br /> SBO-6398(formerly Pib67)(R.11/98) DISTRIBUTION: Original to County,One Copy To:Safety 8 Buildings Division,Owner,Plumber <br />