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DILHR SANITARY PERMIT APPLICATION <br /> In accord with ILHR 83.05,Wis.Adm.Codesommoommmmoommoomma couNTv <br /> �m STATE§,WITAR PERMIT <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than El <br /> 8%x 11 inches in size. ///,k 1f rev�Cs n 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 /> —kms ''/a, S T `0, N, R `I'� E(or) W <br /> PROPERTY OWNER'S MAILING ADDRESS LOT# BLOCK# <br /> 12%1LOA-- 011ik DR , 11 1 <br /> CITY,STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBE <br /> Rmmgd Mtn © (A0) D_ V <br /> II. TYPE OF BUILDING: (Check one) CITY � 1 NEAREST ROAD <br /> State Owned IM TOWN E J�L( o N v/ IE R 019 <br /> El Publicrp? 1 or 2 Fam. Dwelling-#of bedrooms PARCEL ERS 4wl <br /> I " IJV / , , <br /> 111. BUILDING USE: (If building type is public,check all that apply) — t <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.XNew 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 Seepage Bed 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: <br /> 1.GALLONS P7 2.ABSORP.AREA 13.ABSORP.AREA 14. LOADING RATE 5. PERC.RATE 6. SYSTEM ELEV. 7. FINAL GRADE <br /> REQUIRED(sq.ft.) PROPO ED(sq.ft.) Gat/day/sq.ft.) (Min./inch) / ELEVATION <br /> L 2 Q •tp le •� Feet Feet <br /> CAPACITY <br /> VII. TANK Site <br /> in allons Total #of Prefab. Fiber- Exper. <br /> INFORMATION New istin Gallons Tanks Manufacturer's Name oncret Con- Steel glass Plastic App <br /> Tanks Tanks strutted <br /> Septic Tank or Holdin Tank �� <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 tamps) MP/MPRSW No.: Business Phone Number: <br /> Plumber's Address(Street,City,State,Zip <br /> OUNTY/DEPARTMENT USE ONLY ��Jl <br /> Disapproved I Sanitary Permit Fee(includes Groundwater Date Issued—_1 ge ISign m(N t ps) <br /> Approved ❑ Owner Given InitialQI /O J Ry Surcharge Fee) <br /> AdverseD t rminati, `-N VlJ <br /> X. C NDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6399(formerly Plb-67)(R.11/88) DISTRIBUTION: Original to County,One Copy To:Safety 8 Buildings Division,Owner,Plumber <br />