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DILHA SANITARY PERMIT APPLICATION COUNTY r <br /> _ In accord with ILHR 83.05,Wis.Adm.Code <br /> I �•� - STATE SANITARY RERMIT# <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than ///703 X01 g� <br /> 8%x 11 inches in size. ❑ cTeck If reviai 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 /> PR PERTY OWNER PROFI OCATION <br /> (� '/a �%,S Zo T 0, N, R 16 E(or W <br /> PFIOPERTY OWNER'S MAILING ADDRESI_ LOT# BLOCK# <br /> C IWn <br /> CITY,STATE I ZIP CODE PHONE NUMBER <br /> I - -93qq I S <br /> It. TYPE OF BUILDING: (Check one) CITY TP,AREST RC D, <br /> �y{ ❑ State Owned VILLAGE: ER <br /> ❑ Public ,4�„1 or 2 Fam. Dwelling4of bedrooms A N <br /> III. BUILDING USE: (If building type is public,check all that apply) <br /> 1 ❑ ApVCondo <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: (ClAonly 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 ISI Seepage Bed 21 ElMound 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 PERDAY 2.ABSORP.AREA 13.ABSORP.AREA 14. LOADING RATE 15. PERC.RATE 16. SYSTEM ELEV. 7. FINAL GRADE <br /> T REQ IRED(sq.ft.) PROPOSED(sq.ft.) (Gals/day/sq.ft.) (Mi ./inch) ELEVATION <br /> 300 ,(o` v Feet -00 Feet <br /> VII. TANK CAPACITY Site <br /> in allons Total #of Prefab. Fiber- Exper. <br /> INFORMATION New istin Gallons Tanks Manufacturer's Name oncrat Con- Steel glass Plastic App <br /> Tanks Tanks strutted <br /> Septic Tank or Holdina Tank <br /> Lift Pump Tank/Siphon 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 Sts s) MP/MPRSWNo.: Business Phone Number: <br /> I cN142p PJC1nJ {-� ',� ZSm IS 664s-7 <br /> Plumber's Address(street,Ci � <br /> State,Zip Codd): r 893 <br /> a Mil , <br /> Y <br /> IX. COUNTIDEPA(R,nJTMENT USEONLY <br /> El Disapproved Sanitary Permit Fee(Includes Groundwater a issued Issuing Agent gnatu e(N S mps) <br /> r� Surcharge Feel /�� <br /> Approved ❑ Owner Given Initial I- 6 ( ,o <br /> Adverse Determination -J Vl.i <br /> X. CONDITIONS OF APPROVALIREASONS FOR DISAPPROVAL: <br /> SBD-6398(formerly Plb-67)(R.11/88) DISTRIBUTION: Original to County,One Copy To:Safety&Buildings Division,Owner,Plumber <br />