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DILHR SANITARY PERMIT APPLICATION <br /> In accord with ILHR 83.05,Wis.Adm.Code couNry [� <br /> �M�• STATE SANITARI(PERMIT#/qot.�' <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than �yy7� y\M1I <br /> 8%x 11 inches in size. ❑ checkifreviii 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 PSUBDIVISION <br /> OCATION <br /> PROPERTY OWNER' MAILING ADDRESS LOT BLOCK <br /> os C Vt� LrteE <br /> CITY.STA7r A !I ZIP <br /> 7CODE/ PHONE NUMBER NAME OR M NUMBII. TYPE O BUILDI : (Check one) NEAREST ROA❑ Stat@ DWned 67❑ Public IX�1 or 2 Fam.Dwelling-#of bedrooms ERO III. BUILDINGUSE: (If building type is public,check all that apply) x-136- ca- 7Gn <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 /> 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 �SeepageBed 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: Iii <br /> 1.GALLONS PER DAY 2.ABSORP.AREA 3.ABSORP.AREA 4. LOADING RATE 5. PERC.RATE 6. S IM LEV. 7. FINAL RADE <br /> REQUIRED(sq.ft.) PROPOSED(sq.ft.) (Gals/day/sq.ft.) (Min./inch) ELEVATION <br /> ��0 �p�� �j ` a 791eet eet <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 /> Septic Tankor Holdino Tank 0 <br /> Lift Pump Tank/Siphon Chamber CfJ - 7 <br /> VIII. RESPONSIBILITY STATEMENT <br /> I,the undersigned,assume responsibility for installation of the onsite sewage system shown on the attached plans. <br /> Pjt n is Name(Print): Plum IN Sta MP/MPRSW No.: Business Phone Number: <br /> Plumber's Address(Street,city,State,Zip Comr. e <br /> 1 )COUNTY/DEPARTMENT USE ONLY <br /> Disapproved Sanitary Permit Fee(Includes Groundwater a e Issued Issuing Agent Signature(No Stamps) <br /> Surcharge Fee) ^_ n' ^ <br /> Approved ❑ Owner Given initial I�, Q� 10-�j 1�/0 <br /> A v rse Determination <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 6 Buildings Division,Owner,Plumber <br />