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DILHR SANITARY PERMIT APPLICATION <br /> In accord with ILHR 83.05,Wis.Adm.Code COUNTY <br /> STATE ANITARY RMIT# <br /> –Attach complete plans(to the county copy only)for the system,on paper not less than ANITA Y 151 3c9Q <br /> 8'%x 11 inches in size. <br /> Check if revision 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 r <br /> owCk '/a '/a,S T 0, N, IR b E (o W <br /> P PERTY OWNER'S MAILING ADDRESS LOT# BLOCK# <br /> X <br /> CITY,STATE ZIP CODE PHONE NUMBER SU VISIONNAME CSM NUMBER /�QZpU�j`S <br /> (. �� \ <br /> 0 CITY <br /> II. TYPE F BUILDING: (Check one) ❑ State Owned VILLAGE NEAREST ROAD ' / 1` h <br /> �LL�y✓ V �Y <br /> ❑ Public 1or2Fam. Dwelling,#ofbedrooms G PAR EL TA N <br /> Ill. BUILDING USE: (If building type is public,check all that apply) <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.)4 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 ❑ 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 PER DAY 2.ABSORP.AREA 3.ABSORP.AREA 4. LOADING RATE 5. PERC.RATE 6. SYSTEM ELEV. 7. FINAL GRADE <br /> REQUIRED(sq.ft.) PROPOSED(sq.ft.) (Ga/ls/day/sq.ft.) (Min./inch) L,� pELEVATION <br /> G 1 p tc9 S r I Feet 91 00 Feet <br /> VII. TANK CAPACITY Site <br /> in ellons Total #of Manufacturer's Name Prefab. Con- Steel Fiber- plastic Exper. <br /> INFORMATION New istin Gallons Tanks Concrete structed glass App. <br /> Tanks Tanks <br /> Septic Tank orHoldin Tank 000 ank b� i2 <br /> Litt Pum Tank/Siphon Chamber LHI i LH, HL <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 S pill MP/MPRSW No.: Business Phone Number: <br /> leWRRD D S Is 46(m- S <br /> Plumber's Address(Stree,City,State,Zip Code): <br /> 7100 3!�- Wf 5_J6Z (. 5 <br /> IX..COUNTYIDEPARTMENT USE ONLY <br /> ❑ DisapprovedSanitary Permit Fee(Includes Groundwater Date IssuedIssuing Ag t Signature(N Stamps <br /> Approved ❑ Owner Given Initial �,/}} / Surcharge Feel �r1 rd <br /> Adve D rmin tion °r `06' <br /> X. CONDITIONS OF APPROVAUREASONS FOR DISAPPROVAL: <br /> SBD-6398(formerly Plb-67)(R.11/88) DISTRIBUTION: Original to County,One Copy To:Safety 8 Buildings Division,Owner,Plumber <br />