Laserfiche WebLink
rail SANITARY PERMIT APPLICATION <br /> In accord with ILHR 83.05,Wis.Adm. Code C UNTY <br /> Qv)fC l` L <br /> —Attach complete plans(to the county copy only)for the system,on paper not less than ST TE SANITgRY PERMIT# <br /> 8'%x11inchesinsize. <br /> -See reverse side for instructions for completing this application. c eck it revision to previous application <br /> 1. APPLICANT INFORMATION—PLEASE PRINT ALL INFORMATION. ST TE PLAN I.D.NUMBER <br /> PROPERTY OWNER <br /> PROPERTY LOCATION <br /> PROPERTY OWNER'S MAILINGADDRESS 137 , N, R IS'' -E-(er) W <br /> 1 o g' !4t rni� Dove Ji R<Ej <br /> LOT# BLoc # <br /> CITY,S/TATE ZIP CODE PHONE NUMBER <br /> t-ed,o - $ SUBDIVISION NAME OR CSM NUMBER <br /> 11. TYPE OF BUILDING: (Check one) ❑State Owned Lj CINNEAR ST ROAD <br /> VILLAGE: /*, 4Ke <br /> Public ®1or2Fam. Dwelling,#of bedrooms *,ELTAXNUMB R( ) <br /> 111. BUILDING USE: (Ifbuild C- ? <br /> g type is public,check all that apply) C-SL <br /> — <br /> I — <br /> 1 ❑ Apt/Condo �7 <br /> 2 ❑ Assembly Hall 6 ❑ Medical Facility/NursingHome <br /> 3 ElCampground ❑ <br /> Campground 10 ElOut oor Recreational Facility <br /> Merchandise: Sales/Repairs 11 Rest urant/Bar/DinIng <br /> 8 ❑ El❑ Church/School Mobile Home Park 12 ❑ Service Station/Car Wash <br /> 5 ❑ Hotel/Motel 9 ❑ Office/Factory <br /> 13 ❑ Other: Specify <br /> FA) <br /> TYPE OF PERMIT: (Check only one in line A. Check line B if applicable) <br /> . ® New 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5.❑ Repair of an <br /> System System Tank Only ExistingSystem El Y Existing System <br /> B) A Sanitary Permit was previously issued. Permit# <br /> V. TYPE OF SYSTEM: (Check only one) Date Issued <br /> Non-Pressurized Distribution Pressurized Distribution Experimental <br /> 11Seepage Bed Other <br /> ound <br /> 12M <br /> Seepage Trench 22 ❑ In Ground 30 El Specify Type 41 11 Holding Tank <br /> 13 Seepage Pit Pressure 42 ❑ Pit Privy <br /> 14 ❑ System-In-Fill 43 ❑ Vault Privy <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 /> "Soo , <br /> REQUIRED(sq.ft.) PROPOSED(sq.n.) (Gals/day/sq.ft.) (Min./inch) <br /> a- LI 17 ELEVATION <br /> VII. TANK CAPACITY Feet Feet <br /> INFORMATION in alions Total <br /> New istin Gallons Tanks Manufacturer's Name Prefab. Site Fiber- <br /> Tanks Tanks Concrete Con- St el Plastic Exper. <br /> strutted glass qpp <br /> Se tic Ta k or Holdin Tank <br /> Lift Pum Tank/Si hon Chamber <br /> VIII. RESPONSIBILITY STATEMENT <br /> I,the undersigned,assume responsibility for installation of the onsite sewage system shown on the attached plan . <br /> Plumber's Name(Print): Plum er's Signature: No S mps) <br /> /c MP/MPRSW No.: usiness Phone Number: <br /> l.J OPr I� p All S-7 rry <br /> lumber's Address(Street,City,State,Zip Code): <br /> �Yr c lei SV- <br /> IX. COUNTY/DEPAR MENT USE ONLY , <br /> er <br /> ❑ Disapproved Sanitary Permit Fee(Includes Groundwater <br /> Approved ❑ Owner Given Initial (�`l�QJ arge Fee) [a a ssus Issuing it S gn to e N tamps) <br /> Adverse Determination {Ed O--� �r <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> it <br /> SBD-6398(R.08/93) DISTRIBUTION: Original to County,One Copy To:Safety 8 Buildings Division,Owner,Plumber <br />