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17—DILHR SANITARY PERMIT APPLICATION couNTY <br /> In accord with ILHR 83.05,Wis.Adm.Code B r <br /> azt— <br /> STATESNITARY RMIT#1�S5I <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than /� � <br /> 8%x 11 inches in size. ❑ Checkifrewsi to previous application <br /> —See reverse side for instructions for completing this application. STATE PLAN I.D.NUMBER <br /> 1. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION. <br /> PROPERTY OWNER PROPERTY LOCATION <br /> '/a t/.,S T Q, N, R E(O!G <br /> PROPE WNER'S MAI G ADDRESS LOT# BLOCK# <br /> 2 , 7 A ov Ro. ��) t. �_� <br /> 91TY,STATE '•' ZIP CODE PHONE NUMBER <br /> W� V <br /> It. TYPE OF BUILDING: Check one CITY NEAREST ROAD <br /> ( ) State Owned VILLAGE:Q# PF1 (O, 1 ES ,,O 1� <br /> ❑ Public or 2 Fam. Dwelling-#of bedrooms 3 NUM O 1 rl <br /> Ill. BUILDING USE: (If building type is public,check all that apply) �/ -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�Seepage Bed 21 El Mound 30 El SpecifyType 41 El HoldingTank <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 PER DAY 2.ABSORP.AREA 3.ABSORP.AREA 4. LOADING RATE 15. FERC.RATE 6. SYSTEM ELEV. 7. FINAL GRADE <br /> RE RED(sq.tt.) PRO �OS7ED�(sq.ft.) (Gals/day/sq.ft.) (Min./inch) Q ELEVATION <br /> !rte 1�Z /S 7— Feet ?7. 7 Feet <br /> VII. TANK CAPACITY Site <br /> INFORMATION in allons Total #Of Prefab. Fiber- Exper. <br /> New istin Gallons Tanks Manufacturer's Name oncrete Con- Steel glass Plastic A <br /> Tanks Tanks strutted pp' <br /> Septic Tank or Holdina Tank � <br /> Lift Pump 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 Stam ) MP/MPRSW No.: Business Phone Number: <br /> /SIA Q A�k✓N Z(o / - /S <br /> Plumber's Address(Street,City,State,Zip Code): <br /> C) <br /> IX. OUNTY/DEPARTMENT USE ONLY <br /> Disapproved I Sanitary Permit Fee(Includee Groundwater MaleVuefi Issuing Agent SiOD atu s) <br /> Approved E] Owner Given Initial I . surcharge Fee) <br /> AdverseDetermination <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&Buildings Division,Owner,Plumber <br />