Laserfiche WebLink
1.7- <br /> =4 SANITARY PERMIT APPLICATION <br /> DILHRIn accord with ILHR 83.05,Wis.Adm.Code COu <br /> NMIL <br /> STATE SANITARI1�ERMIT#X,,Q <br /> –Attach complete plans(to the county copy only)for the system,on paper not less than ❑ 17� \ <br /> 8%x 11 inches in size. aq <br /> `il <br /> C It revl9l 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 OWNER PROPERTY LOCATION <br /> i '/4 ''/4,S 9 T 40, N, R E (C()W <br /> PROPERTY OWNER'S MAILING ADDRESS _ LbF#� I BLOCK# <br /> ` <br /> Cl ,STATE ZIPCODE PHONE NUMBER SUBDW*lBN+NAM&GRX6ILNYM#ER <br /> $ M VDL 1e . � l i GOV'-�, <br /> It. TYPE OF BUILDIN (Check one CITY N AREST ROAD <br /> ❑ State Owned VILLAGE: O Gp <br /> ❑ Public R1 or 2 Fam. Dwelling,#of bedrooms Z <br /> III. BUILDING USE: (If building type is public,check all that apply) 0 - 4Q0-7-07-6/0 <br /> 1 ❑ Apt/Condo <br /> 2 El Assembly Hall 6 [1 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 12.ABSORP.AREA 3.ABSORP.AREA 4. LOADING RATE 5. PERC.RATE 6. SYSTEM ELEV. 7. FINAL GRADE <br /> REO IRE/�D,(sq.h.) PROPOSED(sq.ft.) (Gals/day/sq.ft.) (Mi ./inch) ELEVATION <br /> 3oa 6 r z S' Feet 0 Feet <br /> VII. TANK CAPACITY Site <br /> ingallons I Total #of Pretab. Fiber- Exper. <br /> INFORMATION New istin Gallons Tanks Manufacturer's Name oncret Con- Steel glass Plastic App <br /> Tanks Tanks structed <br /> Se tic Tank or Holdin Tank W1 — ' <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 /> Plumber's Name(Print): Plumifer's Signature:(No mps) MP/MPRSW No.: Business Phone Number: <br /> rc 14 _S (7rS <br /> Plumber's Address(Street, ity'Sta Zip ): <br /> 2 1-760 PWeW�Bs�R <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> Disapproved Sanitary Permit Fee(Includes Groundwater Date Issuing Agent na r No ) <br /> Scludwpe Fee) <br /> Approved ❑ Owner Given Initial _M f3�. � n�_n� <br /> Adverse Determination <br /> -7� / "/ <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(formerly Plb$7)(R.11/88) DISTRIBUTION: Original to County,One Copy To:Safety&Buildings Division,Owner,Plumber <br />