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DILHF� SANITARY PERMIT APPLICATION <br /> In accord with ILHR 83.05,Wis.Adm.Code COUNTY <br /> DI_ <br /> STATE SANITARY PERMIT#i�� �--- <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than �15a3 <br /> 8%x 11 inches in size. ❑ Check if revision 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 OCATION <br /> PAM(—& �'K `�Z VV'/a F— a, S T C� , N, R E (o W <br /> P OPERTY OWNER'S ILING ADDRESS LOT# BLOCK# <br /> 2 (21 <br /> CITY,STATE I ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER <br /> II. TYPE OF BUILDING: (Check one) ❑ State Owned VILLAGE I NEAREST ROAD <br /> TOWN OF. <br /> �N fl aN A 'R� <br /> ❑ Public 1 or 2 Fam. Dwelling-#of bedrooms 7_ PARCELTAX NUMBER(S) <br /> III. BUILDING USE: (If building type is public,check all that apply) I❑� — 2 — — <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 /> 11; Seepage Bed 21 ❑ Mound 30 El SpecifyType 41 El HoldingTank <br /> 1 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 12.ABSORP.AREA 3.ABSORP.AREA 4. LOADING RATE 5. PERC. RATE 6. SYSTEM ELEV. 7. FINAL GRADE <br /> REQUIRED(sq.ft.) PROPOSED(sq.ft.) (Gals/day/sq.ft.) (Min./inch) ELEVATION <br /> _0 ; Z_ q q Feet (� (_." Feet <br /> VII. TANK CAPACITY Site <br /> in allons Total #of Prefab. Fiber- Exper. <br /> INFORMATION New xisting Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App <br /> Tanks Tanks structed <br /> Se tic Tank or HoldingTank rn �"' ;I-) �' <br /> Lift Pump Tank/Si l Chamber <br /> VI11. 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): PI b is Signature:(No Stamps) MP/MPRSW No.: Business Phone Number: <br /> 'g1CMk'7D Poplef � <br /> Plumber's Address(Street,City,State,JZip Cod ): el 'Q103 <br /> r <br /> IX. COUNTY/DEPART ENT USE ONLY <br /> ❑ Disapproved Sanitary Permit Fee(Includes Groundwater Date IssuedIssuin gent Signature(No Stamps) <br /> Surcharge Fee) <br /> Approved ❑ Owner Given Initial <br /> Adverse Determination -{► J <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 />