Laserfiche WebLink
T,HRF:Tj_ SANITARY PERMIT APPLICATIONIn accord with ILHR 83.05,Wis.Adm.Code couNTY�- STATES ITARY PEkRMIT# O <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than <br /> 8'%x 11 inches in size. ❑ Ch k if revision o previous application <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 PROPERTt/41" <br /> ON <br /> (� C '/4 S T N, R E (or WPROPERTY OWNER'S MAILING ADDRESS` , LOT# BLOCKC 1 �.�L�� VC5�oSTATE 5QODE9%0 PHONE NUMBER SUBDIVISOR CSM NUMBER-5 <br /> 11. TYPE OF BUILDING: (Check one) !7 CITY // 77 CC NEAREST ROAD <br /> ❑ State Owned VILLAGE: Sofa • (•, \ ) O . <br /> ❑ Public /t-�I1 or 2 Fam.Dwelling-#of bedrooms— A LTAx�NM W I` <br /> III. BUILDING USE: (If building type is public,check all that apply) <br /> 1 ❑ Apt/Condo C/1 <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 my one in line A. Check line B if applicable) <br /> A) 1. El New 2. Replacement 3. El Replacement of 4. ❑ Reconnection of 5.El 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 ElMound 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 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/d//ay/sq.ft.) (Min./inch) q ELEVLATIION <br /> >o o IO 3 0 �L ld ( 13- L Feet J Feet <br /> VIL TANK CAPACITY Site <br /> in gallons Total #ofPrefab. Fiber- Exper. <br /> INFORMATION New xistin Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App <br /> Tanks Tanks structed <br /> Se tic Tank or Holding Tank — f P <br /> Lift Pum Tank/SI hon Chamber Ll 0 <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 S mps) MP/MPRSW No.: Business Phone Number: <br /> �C C' o L5c <br /> Plumber's Address(Street,City,StZip Cod ): <br /> 7�)b W'ate, 35 If�f ,tE2 LJI S`I8�13 <br /> I OUNTY/DEPARTMEN USE ONLY <br /> Disapproved Sanitary Permit Fee(Includes Groundwater r9ate Issued as Agent Si nature(No Stamps) <br /> Adverse <br /> OpEl ElO� <br /> owner Given Initial yy.�� surcharge Fee) <br /> Determination ^"' I �O� II-I� <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 />