Laserfiche WebLink
SANITARY PERMIT APPLICATION <br /> 70ILHR In accord with ILHR 83.05,Wis.Adm.Code COUNTY{ T <br /> STATE SAF�N-I`TTA�RI�YP MIT#r�(,�' <br /> –Attach complete plans(to the county copy only)for the system,on paper not less than all <br /> ❑ �� <br /> 8'%x 11 inches in size. c revlewn 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 PROP RTY LOCA tON /_ <br /> /� %a /4, S 67 T09, N, R E (or <br /> PROP RTY OWNER/'S MAILI G DDRESS LOT# BLOCK# <br /> �. I <br /> K <br /> Cly,STAT ZIP CODE, PHONE NUM ER SUBDIVISION NAME OR CSM NUMBER <br /> II. TYPE OF BUILDING: (Check one) ❑ State Owned CITY GE NE T ROAD <br /> ❑ Public 1 or 2 Fam. Dwellingof bedrooms ) F� <br /> III. BUILDING USE: (If building type is public,check all that apply) Di`-900 <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. ElReplacement 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 /> C.I�OtJ REQUIRED(sq.ft.) PROPO/SE/ppP(sq.ft.) (Gals/day/sq.ft.) (Min./inch) LEVATION <br /> oy® A/ Feet . Feet <br /> VII. TANK CAPACITY Site <br /> I <br /> allons Total #of Prefab. Fiber- Exper. <br /> INFORMATION New xistin Gallons Tanks Manufacturer's Name oncrete Con- Steel glass Plastic App <br /> Tanks Tanks strutted <br /> Septic Tank or Holdln Tank <br /> Lift Pum Tank/Si hon 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 S mps) MP/MPRSW No.: Business Phone Number: <br /> �laa�e �3�i <br /> ( 7 15 O 9-7 <br /> Plumber's Address(Street,City,State,Zip Code): <br /> �SirPr� Gt/I A <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> Disapproved Sanitary Permit Fee(includes Groundwater Date ssued Issuing Agent Signature(NoStamps) <br /> LApproved /�� Surcharge Fee)❑ Owner Given Initial Of <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 S Buildings Division,Owner,Plumber <br />