Laserfiche WebLink
��ILHR SANITARY PERMIT APPLICATION <br /> In accord with ILHR 83.05,Wis.Adm.Code COUNTv <br /> STATE S�DUTARY R MIT <br /> –Attach complete plans(to the county copy only)for the system,on paper not less than C '700R <br /> 8'b x 11 inches in size. ❑ Check if revision previous application <br /> See reverse side for IRStrUCtIOn3 for completing this application. STATE PLAN I.D.NUMBER <br /> I. APPLICANT INFORMATION–PLEASE PRINT ALL INFORMATION. <br /> PROPERTY OWNER PENUMBER(S) <br /> CATION <br /> �' '/s,S /1 TS , N, R E(or)® <br /> PRO RTY OWNER'S MAILING ADDRESS ' BLOCK# <br /> ITV.STATE ZIP CODE P/H`-O�NEE NUMBER AME OR CSM NUMBER <br /> �It o foLDING: Check one � NEAREST ROAD <br /> ( ) State Owned PUbIiC 1Or2Fam. DWBIHng�Of bedrOOm3lLUMBER(III. BUILDINGUSE: (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 <br /> f only one in line A. Check line B if applicable) <br /> A) 1. El New 2.ec.Replacement 3. El Replacement of 4. El Reconnection of 5.❑ Repair of an <br /> System ystem 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 El Mound 30 El Specify Type 41 El 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 372.ABSORP.AREA 3.ABSORP.AREA 4. LOADING RATE 5. PERCRATE 6. SYSTEM ELEV. 7. FINAL GRADE <br /> REQUIRED(sq.ft.) PROPOSED(sq.tt.) (Gals/day/sq.tt.) (Min./inch) ELEVATION <br /> j56 643 Mxuo v <br /> '720 -I DI 3 Feet 73.7Feet <br /> VII. TANK CAPACITYin allons Total Site <br /> INFORMATION Tanks <br /> Prefab. Fiber- Expp. <br /> New iati Gallons Tanks Manufacturer's Name ncret Con- Steel glass Plastic App <br /> Tanks Tanks structed <br /> Septic Tank or Holdino Tank <br /> Lia Pump Tank/Siphon Chamber El 1:1 <br /> VIII. RESPONSIBILITY STATEMENT <br /> I,the undersigned,assume responsibility for installation of the onsite sewage system shown on the attached plans. <br /> P ber's Name(Print): Plu is Signature:(No Stamps) 111 <br /> MIP pRSW No.: Business Phone Number: <br /> Z4 d <br /> Plum is Address tree, ity tate,Zip e): <br /> JEZ <br /> x /J76 <br /> IX. COUNTYIDEPARTMENT USE ONLY <br /> Disapproved Sanitary Permit Fee(Includes Groundwater a Issui g ant I nature N Stamps) <br /> Approved Surchuge Fee) - J <br /> pp Owner Given Initial <br /> Adverse <br /> CF <br /> A / _� Gil YJ <br /> D rmin tin �( L/lJ fP �/✓ <br /> X. CO DITIONS OF APPROVAL/REASONS FOR DISAPPROVAL* <br /> SBD-6M(formerly Plb$7)(R.11/88) DISTRIBUTION: Original to County,One Copy To:Safety✓t Buildings Division,Owner,Plumber <br />