Laserfiche WebLink
DIta.HR SANITARY PERMIT APPLICATION <br /> In accord with ILHR 83.05,Wis.Adm.Code COUNTY <br /> r <br /> ���•��_ STATE SANITARYRMIT# <br /> P <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than ❑ Aµ3 <br /> 8'%x 11 inches in size. C���eeeccck if revisi to previous application <br /> —See reverse side for instructions for Completing this application. STATE PLAN I.D.NUMBER <br /> 1. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION. <br /> PROTPE_RTY OWNER PROPERTY LOCATION <br /> �- q • SJE� 114SW %, S T VO, N, R /�o (ocil <br /> PROPERTY OWNER'S MAILING ADDRESS LOT# BLOCK# <br /> ci O 7 icr C cl W C + 7 <br /> CITY,STATE ODE PHONE NUMBER SUBDIVISION NA EOR CSM NUMBER ' <br /> S (`PU1 rw Ha1l _ a `' ° y <br /> II. TYPE OF BUILDING: (Check one) CITY NEAREST F�OAD <br /> (� ❑State Owned ❑ VILLAGE P) rgr TOWN OF:d V & <br /> ❑ Public IST 1 or 2 Fam. Dwelling-#of bedrooms AR L O �/� �P <br /> Ill. 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. M 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 /> 11 ® Seepage Bed 21 ❑ Mound 30 El 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 51 2.ABSORP.AREA 3.ABSORP.AREA 14. LOADING RATE 15. PERC.RATE 6. SYSTEM ELEV. 7. FINAL GRADE <br /> REQUIRED(sq.ft.) PROPOSED(sq.ft.) (Gals/day/sq.ft.) (Min./inch) p VATION <br /> O ( U 4/ 3 �- aJ Q 3 / s-I Feet �'� Feet <br /> VII. TANK CAPACITY Site <br /> in allons Total #of Prefab. Fiber- Exper. <br /> INFORMATION New istln Gallons Tanka Manufacturer's Name oncret Con- Steel glass Plastic App <br /> Tanks Tanks strutted <br /> Se tic Tank or HoldingTank O / C <br /> Lift Pum Tank/Siphon Chamber ",SO / T / <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 nSignatu�r�e:�No Stamps) MP/MPRSWNo.: Business Phone Number: <br /> PM c v01 c � �2 ®3cS' / fs1 <br /> Plumber's Address(Street,Ofty,state,zip Code): <br /> Wo <br /> I . COUNTY/DEPARTMENT USE ONLYi <br /> ❑ Disapproved Satary Permit I"(Includes Groundwater Date IssuedIssum nt Signe e(No Stamps) <br /> Approved ❑ owner Given Initial ` IT (i _ Surcharge Fee) <br /> Adverse Determination T ` � l/l��J q-9 <br /> 91 I <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(formerly Plb-67)(R.11/98) DISTRIBUTION: Original to County,One Copy To:Safety&Buildings Division,Owner,Plumber <br />