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DILH a SANITARY PERMIT APPLICATION <br /> In accord with ILHR 83.05,Wis.Adm.Code COUNTY �, <br /> _. .,,=. ...�-,�, Die_ 1 -030(0 <br /> STATE SANITARY PERMIT# <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than ) 17/LI 5 <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. S$ I - UI Lla(o <br /> PROPERTY OWNER PROPERTY LOCATION <br /> D 0K/9tP 13 41 (_D f'p 7 Acc- X24 A.h.)%, s 3/ T 7, N, R a E (e <br /> PROPERTY OWNER'S MAILING ADDRESS LOT# BLOCK# <br /> �( <br /> 62-73 LI VE.-R-5 /7\( /JJ 7"-4 -- <br /> CITY,STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER <br /> AdPP&I-01*A/ W151335-4,2— ((c:)• )23&3/95 /c/o Le— v 6 r <br /> II. TYPE OF B DING: (Check one) El CITY I NEAREST ROAD <br /> ❑State Owned /PTO N OF /17 i',9,0L�.T.../ A/°`.c- (41,e4E).' G',- <br /> ❑ Public 1 or 2 Fam.Dwelling-#of bedrooms y PARCEL TAX NUMBER(S) <br /> III. BUILDING USE: (If building type is public,check all that apply) 0 7V Q - 3 i ,, — �,a.c L// <br /> i El AptCondo v L/ i <br /> 2 El Assembly Hall 6 El Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility <br /> 3 El Campground 7 El Merchandise: Sales/Repairs 11 ❑ Restaurant/Bar/Dining <br /> 4 ❑ Church/School 8 El Mobile Home Park 12 El Service Station/Car Wash <br /> 5 El Hotel/Motel 9 El Office/Factory 13 ❑ Other: Specify <br /> IV. TOF PERMIT: (Check only one in line A. Check line B if applicable) <br /> A) 1. New 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 05.❑ Repair <br /> System System Tank Only Existing System 0 1 Existing m <br /> • <br /> B) ❑ A Sanitary Permit was previously issued. Permit# __ Date Issued 4. C`,� Cl U 0 4 <br /> V .TYPE OF SYSTEM: (Check only one) a* '-P7 Q•. <br /> Q• <br /> Non-Pressurized Distribution Pressurized Distribution Experimental Oth ,› �Q <br /> 11 El Seepage Bed 21 Mound 30 El Specify Type 41 *ng Tank • <br /> 12 El Seepage Trench 22 ❑ In-Ground 42 ❑ : :~ <br /> 13 El Seepage Pit Pressure 43 El VaifkXy <br /> 14 El 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.) (Gals/day/sq.ft.) (Min./inch) ELEVATION <br /> C-20o -S-00 ..---- <br /> Ct3 .�DU A Z Z.3 97. Z Feet p ....5-Feet <br /> VII. TANK CAPACITY Site <br /> in gallons Total #of Prefab. Fiber- Exper. <br /> 'INFORMATION New Existing Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App. <br /> Tanks Tanks structed <br /> (e Tanr Holding Tank /ZSoo — /fib 1 c/P El El ❑ El El <br /> `Litt Pump Taidiphon Chamber 7 So — 7-t'D / - El Li El El ❑ <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 Si nat Stamps) MP/MPRSW No.: Business Phone Number: <br /> //AC* aeSe n•/34%41r a<.! 3 3 7i 7 (6 d e ) F73 -*7 ec <br /> Plumber's Address(Street,City,State,Zip Code): <br /> 30Z &_rif A/ 4-,,7i'/-1-6Z- 6e0e:G z,e,,5 5-?5:z-7 <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved Sanitary Permit Fee(Includes Groundwater Date Issued Issuing Agent Signature(No St m s) <br /> Surcharge Fee) <br /> Approved ❑ Owner Given Initial $ LI( (O t 00 7—S-g C /7��'2 �� <br /> Adverse Determination �( / <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 />