Laserfiche WebLink
DILHR SANITARY PERMIT APPLICATION <br /> In accord with ILHR 03.05,Wis.Adm.Code COUN T <br /> �L1�r <br /> STATE$ANITAR PERMIT Id ql?� <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than CC 10-I <br /> 8'/z x 11 inches in size. ❑ Check if rev a n 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 /> Bob Phetps '/4 '/s, S 20 T47 , N, R 76 E(o W <br /> PROPERTY OWNER'S MAILING ADDRESSLOT# BLOCK# <br /> Rt. #1 Box 185 ,13aQ-v�G Y2, Yom. Lo-T- I <br /> CITY,STAJE. ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER <br /> Ba ,n, (VI 54002 715 84-3937 pct. SE SE <br /> 11. TYPE OF BUILDING: (Check one) El State Owned VILLAGE NEAREST ROAD <br /> 0 CITY <br /> SWiZ,5 ' Oak Stt eet <br /> ❑ Public ©1 or 2 Fam.Dwelling-#of bedrooms 2 LAX NUM ( ) <br /> 111. BUILDING USE: (If building type is public,check all that apply) <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. X❑ 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 El 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 15. PERC.RATE 6. SYSTEM ELEV. 7. FINAL GRADE <br /> REQUIRED(sq.ft.) PROPOSED(sq.ft.) (Gals/day/sq.ft.) (Min./inch) ELEVATION <br /> 300 480 720 .42 4 95.3 Feet 97.6 Feet <br /> VII. TANK CAPACITY Site <br /> in gallons Total #of Prefab. Fiber- Exper. <br /> INFORMATION New istin Gallons Tanks Manufacturer's Name oncret Con- Steel glass Plastic App <br /> Tanks Tanks strutted <br /> Septic Tank or Holdina Tank 800 00 1 Skaw <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): Plumber's Signature:(No Stamps) MP/MPRSW No.: Business Phone Number: <br /> Glade Rujzho2m 1 3361 715 49-7286 <br /> Plumber's Address(Street,City,State,Zip Code): <br /> 24702 Lind Road P.U. Box 514 SiAen, U/I 54872 <br /> IX.jiCOUINTYIDEPARTMENT USE ONLY <br /> ❑ <br /> Disapproved Sanitary Permit Fee(in clutlse Grountlwater Date IssuedIssuin g t Signat (No Stamps) <br /> Approved ❑ Owner Given Initial �'?� Surcharge Fee) /,� �j <br /> Adv Determination J ls� )- oo —/�~/� 'G� <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 />