Laserfiche WebLink
,75ILHR SANITARY PERMIT APPLICATION <br /> COON' <br /> In accord with ILHR 83.05,Wis.Adm.Code <br /> _,.° _ L— <br /> mmmms <br /> STATE S/ANITARY PE MIT# 03a� <br /> –Attach complete plans(to the county copy only)for the system,on paper not less than (� <br /> 8%x 11 inches in size. ❑ Cheek If revision revioue appllcatlon <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 rPROPERTYY LOCATION <br /> K i 9, %50 ,/4, S ZZ T Q, N, R E(orPROPERTY OWNER'S MAILING ADDRESS BLOCK# <br /> r A IR <br /> CITY,STATE ZIPC DE PHONENUMBER <br /> 0 <br /> ILDING: (Check One) Y NEAREST ROAD <br /> ❑ State Owned LAGE 0 I.\ n <br /> ❑ Public �1 or 2 Fam.Dwelling,#of bedrooms A Ax UM ) IJ V <br /> 111. BUILDING USE: (If building type is public,check all that apply) 4eo <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 /> 11Seepage Bed 21 ❑ Mound 30 EJSpecify 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 51 2.ABSORP.AREA 3.ABSORP.AREA 14. LOADING RATE 15. PERC.RATE 16. SYSTEM ELEV. 7. FINAL GRADE <br /> REQUIRED(sq.ft.) PROPOSED(sq.ft.) (Gals/day/sq.ft.) (Mindinch) (� / ELEVATION <br /> H 5 GIt 5 a 9 q r (O Feet t Feet <br /> VII. TANK CAPACITY Site <br /> in allons Total #of Prefab. Fiber- Exper. <br /> INFORMATION New istin Gallons Tanks Manufacturer's Name oncrete Con- Steel glass Plastic App <br /> Tanks Tanks strutted <br /> Septic Tank or Holding Tank <br /> Lift Pump Tank/Sipon Chamber <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 Signature:(No Stam ) MP/MPRSWNo.: Business Phone Number: <br /> yrs <br /> Plumber's Address(Street,City,State,Zip Code): <br /> �1( c) Aw _5 wt13Szn- <br /> I COUNTY/DEPARTMEN USE ONLY <br /> Disapproved Sanitary Permit Fee(Includes Groundwater aIssued Issug gent Sign (No Stamps) <br /> O.Approved ❑ Owner Given Initial �� Surcharge F.) � �O <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 8 Buildings Division,Owner,Plumber <br />