Laserfiche WebLink
SANITARY PERMIT APPLICATION COUNTY <br /> 17,UILHR In accord with ILHR 83.05,Wis.Adm.Code u v n f ! L <br /> STATE NITAR PERMIT#)qSY30 <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than <br /> 8'fi x 11 inches In size. ❑check if revis n to previous application <br /> -See reverse side for Instructions for completing this application. STATE PLAN I.D.NUMBER <br /> I. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION. S 93- <br /> PROPERTY OWNER PROPERTY LOCATION <br /> all N l'a hA Ya u 3W 1/,S 6Ya, S , T`/a , N, R /6 E-* W <br /> PROPERTY OWNER'S MAILING ADDRESS LOT# ^ BLOCK# <br /> o Ave- E. <br /> CITY,STATE ZIP CODE PHONE N MBER SUBDIVISION NAME OR CSM NUMBER <br /> VK 55�Ofo � <br /> If. TYPE OF BUILDING: (Check one) Lj <br /> CITY / NEAREST ROAD r <br /> State Owned VILLAGE: 4 K�4k d Lo 614i4 1 d <br /> ❑ Public ®1 or 2 Fam.Dwelling-#of bedrooms ;L ;= . <br /> PARNUMI3tx1,5, <br /> Ill. BUILDING USE: (If building type is public,check all that apply) aQ O — 4 v <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. �4 Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5.❑ Repair of an <br /> System System Tank Only 2 Existing System Existing System <br /> ll��I( <br /> B) L'3 A Sanitary Permit was previously issued. Permit# �J $`S Date Issued <br /> V. TYPE OF SYSTEM: (Check only one) <br /> Nan-Pressurized Distribution Pressurized Distribution Experimental Other <br /> 11 ❑ Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 N Holding Tank <br /> 12 ❑ Seepage Trench 22 ElIn-Ground42 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 15. PERC.RATE6. SYSTEM ELEV. 7. FINAL GRADE <br /> REQUIRED(sq.ft.) PROPOSED(sq.ft.) (Gals/day/sq.ft.) (Min./inch) ELEVATION <br /> 30o I I I Feet Feet <br /> VII. TANK CAPACITY Site <br /> in allonS Total #of Prefab. Fiber- Exper. <br /> INFORMATION New istin Gallons Tanks Manufacturer's Name oncret Con- Steel glass Plastic App <br /> strutted <br /> Tanks Tanks <br /> Septi,TankOCHoldinit Tano X Wieserct <br /> Lia Pump Tank/Siphon Chamber F1 F1 F1 F1 Fj Fj <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): PI bar's Signatu e:(N)Stamps) MP/MPRSW No.: Business Phone Nu�mbepr:� <br /> Plumber's�Addddress(Street,City,State,Zip Code): <br /> C Sl D f f <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> Disapproved Sanitary Permit Fee(incluom Groundwater a al esu I Issuing A t Sign re(N s) <br /> ASurcharge Fee)pproved ❑ Owner Given Initial <jj"`13 _E?_1-7� <br /> Adv Determin tion lP 5. <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 />