Laserfiche WebLink
SANITARY PERMIT APPLICATION COUNTY <br /> Lft�=l�r•ln In accord with ILHR 83.05,Wis.Adm.Code <br /> STATE SANIT RV PERMIT g <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than ��'�j j, rj a <br /> 8'/4 x"11 Inches in size. ❑ Check if revision to previous application <br /> wee reverse side for instructions for completing this application. sT E PLAN I.D.NUMBE/R <br /> I. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION. 1 - a�O7 6 <br /> PROPERTY OWNER r PROPERTY LOCATION <br /> '/4 ''/s, S T-57 , N, Rf E(or W <br /> PROPERTY OWNER'S MAILING ADDRESS LOT#� <br /> CITY,STATE IP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER <br /> If. TYPE OF BUILDING: (Check one) CITY NEAREST ROAD <br /> ❑ State Owned O VILLAGE �— <br /> ❑ Public VN 1 or 2 Fam. Dwelling-#of bedrooms— PARCEL AX NUMBERS) <br /> III. BUILDING USE: (If building type is public,check all that apply) -�a- <br /> 1 ElApt/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. TYI��P77E�I OF PERMIT: (Check only one in line A. Check line B if applicable) <br /> A) 1. lel 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 /> f <br /> 11 ❑ Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 1a Holding Tank <br /> 12 ❑ Seepage Trench 22 ❑ In-Ground 42 ❑ Pit Privy <br /> 13 ❑ Seepage Pit Pressure 43 ❑ Vault Privy <br /> 14 ❑ Systpm-In-Fill <br /> VI. ABSORPTION SYSTEM INFORMATION: <br /> 1.GALLONS PER DAY 2.ABSORP.AREA 13.ABSORP.AREA 14. LOADINGRATE 15. PERC. RATE 115. SYSTEMELEV. 7. FINAL GRADE <br /> REQUIRED(sq.ft.) PROPOSED(sq.ft.) (Gals/day/sq.ft.) (Min./inch) ELEVATION <br /> e7 e? Feet Feet <br /> VII. TANK CAPACITY "NConcrete <br /> Site Fiber- Exper. <br /> in r1lons Total #of ]Manufacturer'sCon- Steel PlasticINFORMATION NewGallons Tanks strutted91ass App. <br /> TankHoldin Tank 0 ��� ' <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 plans. <br /> Plumber's Name(Print): Plumber's Signature:(No S ) MP/MPRSW No.: Business Phone Number: <br /> Grpllf .Pe>�sil%, <br /> Plumber's Address(Street,city,Stale,Zip Code): <br /> .'� �t//it-''7 lam✓�_ <br /> IX. COUNTY/DEPARTMENT USE ONLY Issu' A nt Si at re(N tam ) <br /> ❑ Disapproved SanitaryPermit Fee(Includes Groundwater a e ssue 9 <br /> surcharge Feel <br /> Approved ❑ Owner Given Initial � `l'I <br /> Adverse Determination <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBa6398(R.08/93) DISTRIBUTION: Original to County,One Copy To:Safety8 Buildings Division,Owner,Plumber <br />