Laserfiche WebLink
SANITARY PERMIT APPLICATION <br /> E <br /> � COUNTY <br /> In accord with ILHR 83.05,Wis.Adm.Code ��W <br /> STAT SANIT�n�1�YPERMIT#t <br /> —Attach complete plans(tot the county copy only)for the system,on paper not less than ?h6� lJ Sm 30 <br /> 8'%x 11 inches in size. 11 <br /> Check if revision to previous application <br /> -,See reverse side for instrU tions for completing this application. STATE PLAN I.D.NUMBER <br /> I. APPLICANT INFORMATION—PLEASE PRINT ALL INFORMATION. <br /> PROPERTY OWNER PROPERTY LOCATION <br /> LIL '/4 '/4, S 6 T 30, N, R 5 E(o <br /> PROP RTY OWNER'S MAILING ADDRESS LOT# BLOCK# <br /> N . I G .G. <br /> CITY,STATE IP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER <br /> u� rJ . ro <br /> II. TYPE OF BUILDING: (Ch Ck one) Ll CITY NEAREST ROAD <br /> ❑ State Owned O VILLAGE :LA A)UE7M W/NO 5X1 <br /> ❑ Public �1 or am. Dwelling—#of bedrooms 3 PARCEL TAX NUMBER(5) <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. El Replacement 3.JR�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: (Cht ck only one) <br /> Non-Pressurized Distribu ion 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 NFORMATION: <br /> 1.GALLONS PER DAY 12.AE SORP.AREA 13.ABSORP.AREA 14. LOADING RATE 15. PERC.RATE 6. SYSTEM ELEV. 7. FINAL GRADE <br /> RE/IQ IRED(sq.ft.) PROPOSQED(sq.ft.) (Gals/day/sq.ft.) (Min./inch) (;EELEVATION <br /> so t0 G O r 1 /___ '7 Feet �I ! •Z- Feet <br /> CAPACITY <br /> VII. TANK Site <br /> in allons Total #of Prefab. Fiber- Exper. <br /> INFORMATION New istin Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App <br /> anks Tanks strutted <br /> Septic Tank or Holding Tank <br /> Lift Pum Tank/Si hon Chamber <br /> Vlll. RESPONSIBILITY STATEMENT <br /> I,the undersigned,assume re ponsibility 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 NumberPwfixo : <br /> wS 946 15'7 <br /> lumber's Address(Street,City,S1 te,Zip Code): <br /> z bo w 3 7 wc,65r g W1• S� 3 <br /> IX. COUNTY/DEPARTMENTUSE ONLY <br /> ❑ Disapproved Sanitary Permit Fee(Includes Groundwater a e ssue Issu ge Sigpa r IN S mps) <br /> Approved ❑ Owner Given Initial Surcharge Feel ,y/ \\tl <br /> Adverse Det rmination 9 a it <br /> X. CONDITIONS OF APPROVAL/REASONS;FOR DISAPPROVAL: <br /> SB0.6398(R.08/93) DISTRIBUTION: Original to County,One Copy To:Safety&Buildings Division,Owner,Plumber <br />