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SANITARY PERMIT APPLICATION <br /> 17—DILHR <br /> In accord with ILHR 83.05,Wis.Adm. Code COUNTY <br /> STATErS A PER ),,,S1419 <br /> I'd <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than 1� J`I 48%x 11 inches in size. ❑ Ceviei 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 OWNERPERTY ATION <br /> NAL-� KO /a CAP, '/4, S T VON, R E(o <br /> PROPERTY OWNER'S MAI G ADDRE L T# BLOCK# Ale <br /> ok� Do . <br /> CITY,STATE ZIP CODE PHONE NUMBER SWI&QUISIDILHWE OR CSM <br /> t 0.3 C1 T <br /> It. TYPE OF UILDING: Check one ITS NEA ST ROAD <br /> ( ) State Owned ILLAGE <br /> ❑ Public 1or2Fam. Dwelling-#ofbedrooms <br /> III. 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_ <br /> P OF PERMIT: (Ch ck only one in line A. Check line B if applicable) <br /> A) w 2. Replacement 3. ❑ Replacement of 4. El Reconnection of 5.L1 Repair of an <br /> ystem 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 �I Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank <br /> 12�E `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 Ej 2.ABSORP.AREA 3.ABSORP.AREA 4. LOADING RATE 15. PERC.RATE 16. SYSTEM ELEV.4sp141VATION <br /> INALGRADE <br /> RE UIRE sq.ft.) P OPO ED(sq.ft.) (Gals///day/sq.ft.) (Mi ./inch) <br /> a 69 Feet ,d Feet <br /> CAPACITY <br /> VII. TANK Site <br /> in allons Total #of Manufacturer's Name Prefab. Con- Steel Fiber- plastic Exper. <br /> INFORMATION New xistin Gallons Tanks oncret glass App. <br /> Tanks Tanks structed <br /> Septic Tank or Holdino 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 /> P ber'a Name(Print): P ¢ is Signature: No mps) MP/ P S o.: Business ho N mbar: <br /> A D PAIN P I <br /> I r�ber a AQdress Stre ,State,Zi Cod <br /> I COUNTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved Sanitary Permit Fee(includes Groundwater ae seas Issuing Agent Si natur (No tamps) <br /> Approved El Owner Given Initial surcharge Fee) <br /> Adverse Determination <br /> l05 0D W <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: 10 <br /> SBD-6396(formerly Plb-67)(R.11/98) DISTRIBUTION: Original to County,One Copy To:Safety&Buildings Division,Owner,Plumber <br />