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( DILHR SANITARY PERMIT APPLICATION <br /> In accord with ILHR 83.05,Wis.Adm.Code cPVNTY <br /> STATE SANITARY PERMIT# I R 21$� <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than (15 6 <br /> 8'%x 11 inches In size. ❑ Check if revision to previous application <br /> -See reverse side for instructions for completing this application. ST!M I.D. BE <br /> I. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION. <br /> PROPER OWNER PROPERTY LOCATION <br /> �o% '/4 Y4, S T Y� N, R / E (Or <br /> PROPER OWNER'S MAILIN DDRESS LOT# BLOCK# <br /> 1h e. S• <br /> CITY,STAT ZIP CODE PHONE NUMBER SUBDI ION NAME OR CSM UMBER <br /> o. . Clu/ lz7v 50 _ V <br /> It. TYPE OF BUILDIN : (Check one) LlState Owned CITY <br /> NYRE RAD <br /> VLLn J4. <br /> ❑ Public 1 or 2 Fam. Dwelling-#of bedroom .R SAX NU ( ) <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. LXI Replacement 3. El Replacement of 4. ❑ Reconnection of 5.❑ Repair of an <br /> System rl 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 Oth,,,,e,,r(((( <br /> 11 <br /> El Bed 21 El Mound 30 1:1 Specify Type 41 Holding Tank <br /> 12 ❑ Seepage Trench 22 ElIn-Ground42 ❑ 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 /> 3 ^ REQUIRED(sq.ft.) PROPOSED(sq.ft.) (Gals/day/sq.ft.) (Min./inch) ELEVATION <br /> I Feet Feet <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 structed <br /> Septic Tank or Holdin Tank _ &_ <br /> Lift Pump Tank/Si hon 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/MPRSW No.: Business Phone Number: <br /> IX <br /> Plumber's Address(Street,City,5 e,Zip Code): _ <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved Sanitary Permit Fee(Includes Groundwater Date IssuedIs in gent Signat a oStamps) <br /> Approved ❑ Owner Given Initial 11 Surcharge Fee) `Vi <br /> Adve enIniti i n $V (D ` ` <br /> . CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-8398(formerly Plb-67)(R.11/88) DISTRIBUTION: Original to County,One Copy To:Safety&Buildings Division,Owner,Plumber <br />