Laserfiche WebLink
DIS_ .HR SANITARY PERMIT APPLICATION <br /> In accord with ILHR 83.05,Wis.Adm.Code COUNTY <br /> I <br /> STATE SANITAR RMIT# <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than � ��A� <br /> 8'%x 11 inches in size. 1:1Check If reviabh to prevloua 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 /> PfiWERTY OWNER P OPERTY OC ION <br /> L '/a <br /> P OPERTY OWNER'S MAILING ADDRESS LOT t;{ <br /> L <br /> CITY, TATE ZIP COD PHONE NUM R SUBDIVISION NAME OR CSM NUMBER <br /> PC <br /> Milk)- S( 16.'Z3.bio n <br /> 11. TYPE OF BUIL NG: (Check one) ❑ State Owned VILLAGE NEAREST T�o9n <br /> Public 1 or 2 Fam. Dwelling <br /> of bedrooms— A UMBER(S) <br /> Ill. BUILDING USE: (If building type is public,check all that apply) U—�3�3 <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.XReplacement 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 ElSpecify 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 /> REQUIRED(sq.ft.) PROPOSED(sq.ft.) (Gals/day/sq.ft.) (Min./inch) ELEVATION <br /> 2_0 (o2, S Feet 0 I.0 Feet <br /> VII. TANK CAPACITY Site <br /> in allons Total #of Prefab. Fiber- Exper. <br /> INFORMATION New istin Gallons Tanks Manufacturer's Name c ncret Con- Steel glass Plastic App <br /> Tanks Tanks strutted <br /> Septic Tank or Holdinct Tank <br /> Lift Pum Tank/ i hon Chamber <br /> Vlll. 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): 1.PWpej-s Signature:(No Sta I MP/MPRSW No.: Business Phone Number: <br /> G Z� / X66` 5 <br /> lum r' ddress(St eel.City,State,Zip Code): <br /> 2 0 W STE 1 - 54"31':� <br /> IX. ,COUNTY/DEPARTIMENT USE ONLY <br /> ❑ Disapproved Saniittaary Permit Fee(Includes Groundwater Date Issuing Agent Signature(No Stamps) <br /> � pproved ❑ Owner Given Initial ql 10 <br /> surcharge Feel ^j <br /> Adverse Determination lY <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: (Lt l <br /> SBD-6398(formerly Plb-67)(R.11/88) DISTRIBUTION: Original to County,One Copy To:Safety&Buildings Division,Owner,Plumber <br />