Laserfiche WebLink
SANITARY PERMIT APPLICATION <br /> COUNTY <br /> -Attach <br /> In accord with ILHR 83.05,Wis.Adm.Code <br /> STATE SCANIT Y PERMIT# 1 <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than T � �(.fOd <br /> 8'/z 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 LOCATION <br /> /a '%, S 1I T 4p, N, R I �W <br /> PROPERTY OWNER'S MAILIN ADDRES11S__ Ave. LOT# BLOCK# <br /> O WgSHtr1 Ton A 122_ 1`11A <br /> CITY,STATE ZI ODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER <br /> 141P L:I2n 55415 (ml 2- OS''S n R <br /> II. TYPE O BUILDING: Check one CI NEAREST ROAD <br /> ( ) State Owned ❑ VILLADEAd JOWN OF: c_..y t, r.1 , <br /> ❑ Publlc �, 1 or 2 Fam.Dwelling,#of bedrooms� PAR ELTAX NUMBERS) t-..[x �r'F' <br /> III. BUILDING USE: (If building type is public,check all that apply) —�( l t � ,-( 00 <br /> 1 ❑ Apt/Condo LLL <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 ❑ 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.) (Gals/day/sq.ft.) (Min./inch) ELEVATION <br /> 450 (04:5 4 . 7 V11of L,, Q5.$ Feet C(y,O Feet <br /> VII. TANK CAPACITY Site <br /> in gallons Total #of Manufacturer's Name Prefab. Con- Steel Fiber- Plastic Exper. <br /> INFORMATION New xistin Gallons Tanks Concrete glass App. <br /> Tanks Tanks strutted <br /> Septic Tank k Tanks <br /> Ioeo <br /> Lift Pump Tanta er 170 <br /> VIII. RESPONSIBILITY STATEMENT <br /> I,the undersigned,assume responsibility for installation oft a onsite sewage system shown on the attached plans. <br /> Plumber's Name(Print): lumber's Signature:(No Stamps) 1/D/MPRSW No.: Business Phone Number: <br /> 4V_+er 3,/3 ?j g- �35- 2qBZ <br /> Plum bet's Address(St t,City,State,Zip Code): <br /> IIACR 5 (box 4'7 i —4801 <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> Disapproved Sanitary Permit Fee(Includes Ground water Date IssuedIssuing gent Sign t re(No tamps) <br /> Approved ❑ Owner Given Initial ' r---`jyurcharge Fee) �I ^ <br /> Adverse Determination J v �-V` Y <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: 71 <br /> SBD-6398(R.08/93) DISTRIBUTION: Original to County,One Copy To:Safety 8 Buildings Division,Owner,Plumber <br />