Laserfiche WebLink
7DILHR SANITARY PERMIT APPLICATION COUNTY <br /> In accord with ILHR 83.05,Wis.Adm.Code <br /> STATFFFFjjjj���SANITA ER"2_3 <br /> —Attach complete plans(to the county copy only)for the system,on paper not less than ❑ 1(o�J�l <br /> 8%x 11 Inches In size. (heck if re!)to <br /> wee 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 /> TAID LL `'A '/a, S Q3 T q0, N, R 157 E(or) W <br /> PROPERTY OWNER'S MAILING ADDRESS LOT# BLOCK# <br /> i M A- IS' <br /> CITY,STATE I ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM UMBER <br /> II. TYPE OF BUILDING: (Check one) CITY yt NEAREST ROAD <br /> LJ Owned VILLAGE JTQWN OF.- nr D� OVEPLflNn FD _ <br /> ❑ Public 1 or 2 Fam. Dwelling•#of bedrooms 2 L TAX NUM <br /> III. BUILDING US : (If building type is public,check all that apply) 5�— Off_`✓<C..I.J <br /> GaT-IS <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.)Q 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 ❑ Specify Type 41 ❑ Holding Tank <br /> 12 M 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 14. LOADING RATE 5. PERC.RATE 16. SYSTEM ELEV. 17. FINAL GRADE <br /> REQUIRED(sq.ft.) PROPOSED(sq.ft.) (Gals/day/sq.ft.) (Min./inch) 19`414 ELEVATION <br /> 3 00 o O� r Feet 946-0 Feet <br /> VII. TANK CAPACITY Site <br /> in allons Total #of Prefab. Fiber- Exper. <br /> INFORMATION New istin Gallons Of Manufacturer's Name oncret Con- Steel glass Plastic App <br /> Tanks Tanks <br /> strutted <br /> Septic Tank or Hold no Tank <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 tamps) MP/MPRSW No.: Business Phone Number: <br /> 3`fV 'L <br /> PI mber's Address(Street,City,State,Zip Code): <br /> 1_11 <br /> L 7't�6 LJEtiS11-:�1Z W 1 . Sq} ` 3t <br /> IX. gOUNTYIDEPARTMENT USE ONLY <br /> ❑ Disapproved Sanitary Permit Fee(Incluaea Groundwater ate Issued IssuingA Signature No mps) <br /> Surcharge Fee) <br /> pproved ❑ Owner Given Initial -t I r�� /F-i"�. <br /> Adverse [ rmin i n _ '1 i V lJU <br /> X. CONDITIONS OF APPROVALIREASONS FOR DISAPPROVAL: <br /> SBD-6398(formerly Plb-67)(R.11/98) DISTRIBUTION: Original to County,One Copy To:Safety 8 Buildings Division,Owner,Plumber <br />