Laserfiche WebLink
SANITARY PERMIT APPLICATION <br /> DIL IR In accord with ILHR 83.05,Wis.Adm.Code couNTY <br /> STATE SANITARY,PERM IT# cf7'�4YJI <br /> —Attach complete plans(to the county copy only)for the system,on paper not less than <br /> 8'%x11inches insize. ❑ Check If revialph 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. <br /> PROPERTY OWNER r PROPERTY LOCATION <br /> Q '/4 ''/4, S TtB <br /> N, R ILI E(or W <br /> PROPERTY OWNER'S MAILING ADDRESS LOT# OCK# <br /> CITY,STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER <br /> I!iHN2_ 1( — NmV. iq P. I L In G✓''�, 1� , r-- <br /> 11. TYPE OF BUILDING: (Check one) CITY N REST ROAD <br /> ❑State Owned VILLAGE <br /> ❑ Public ®1 or 2 Fam. Dwelling—#of bedrooms 2 NT, L rI <br /> III. BUILDING USE: (If building type is public,check all that apply) — 4,:_jc>(— ��-- <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.,RReplacement 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 X Seepage Bed 21 ❑ Mound 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 12.ABSORP.AREA 3.ABSORP.AREA 14. LOADING RATE 15. PERC.RATE 16. SYSTEM ELEV. 7. FINAL GRADE <br /> REQ IRED(sq.ft.) PROPOSED(sq.ft.) (Gals/day/sq.ft.) (Min./inch) ELEVATION <br /> 7 Q ,l`oz 3 1 q2 - Feet Feet <br /> CAPACITY <br /> VII. TANK Site <br /> in allons Total #of Prefab. Fiber- Expp. <br /> INFORMATION New istin Gallons Tanks Manufacturer's Name oncrete Con- Steel glass Plastic App <br /> Tanks Tanks strutted <br /> Septic Tank or Holdina Tank <br /> Litt Pump Tank/Siphon Chamber <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 lam MP/MPRSW No.: Business Phone Number: <br /> PIlimber's Address Street,City, tate,Zip Code): <br /> '�1 w 35 ' . ECB W6 M3 <br /> IX. lCOUNTYIDEPARTMENT U E ONLY <br /> ❑ DisapprovedSanitary Permit Fee(Includes Groundwater a e ssu Issuing gent Signature(No Stamps) <br /> Approved ❑ Owner Given Initial Surcharge Fee) <br /> A m in 1E _ .Co - 17—� 1 <br /> X. CdNDITIONS 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 />