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DILMR SANITARY PERMIT APPLICATION COUNTY <br /> In accord with ILHR 83.05,Wis.Adm.Code <br /> STATE,SANITARY RMIT#I QT'fQ <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than C 3 uV f <br /> 8'%x 11 inches in size. E] cneck n revlslo o 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 /> R ELL,_ r-%,- ''/a, S T C , N, R IS E (or W <br /> PROPERTYOWNER'S MAILING ADDRESS LOT# BLOCK# <br /> z3 LARr5�n/ v aU - — <br /> CITY,STATE ZIPCODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER <br /> Ft rJo M l 0 z o- <br /> It. TYPE OF BUILDING: (Check one) Lj CITY NEEARE�S•TQROAiD' p <br /> I�7 ❑ State Owned VILLAGE Sin( S �C BE I J K 0 - <br /> ❑ Public C01 or 2 Fam.Dwelling-#of bedrooms Z L UM <br /> III. BUILDING USE: (If building type is public,check all that apply) 10,— q a V I — !O --7lJ�-' <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 /> 11Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank <br /> 12 MSeepage 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 13.ABSORP.AREA 14. LOADING RATE 5. PERC.RATE 6. SYSTEM ELEV. 7. FINAL GRADE <br /> REO RED(sq.H.) PROPOSED(sq.k.) (Gals/day/sq.ft.) (M'n/inch) Qom( ELEVATION <br /> 3Q0 0 Lot "(l • � Feet Feet <br /> VII. TANK CAPACITY Site <br /> ingallons Total #of Prefab. Fiber- Exper. <br /> INFORMATION New xistin Gallons Tanks Manufacturer's Name oncrete Con- Steel glass Plastic App <br /> Tanks Tanks strutted <br /> Septic Tank or Holdina Tank 115DI ._ L <br /> I Ll <br /> Lift Pump Tank/Siphon Chamber <br /> VIII. RESPONSIBILITY STATEMENT <br /> 1,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 /> &99e.10 HOPKIW-5 <br /> Plumber's Address(Street,city,State,Zip Code: <br /> �_? o 14wSS I,J�BS W r. 93 <br /> IX.4OUNTYIDEPARTMEW USE ONLY <br /> ❑ Disapproved 1 Sanitary Permit Fee(includes Groundwater rte IssuedIssuing Ag SI re( s) <br /> Io CFOsurcFee) <br /> A ❑ <br /> Approved Owner Given Initial �_3� <br /> Adverse D t rmination <br /> X. CONDITIONS OF APPROVALIREASONS FOR DISAPP OV : <br /> ��r <br /> of L <br /> SBD-6398(formerly Plb-67)(R.11/88) DISTRIBUTION: Original to County,One Copy To:Safety&Buildings Division,Owner,Plumber <br />