Laserfiche WebLink
SANITARY PERMIT APPLICATION <br /> DILHR In accord with ILHR 83.05,Wis.Adm. Code C uNTY 64" <br /> LYYI� / ,� <br /> STA E SANITARY ERM T# <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than sc,�� P` 9 <br /> $%X 11 IRCheS In size. ❑ 'heck It revision to previous application <br /> -See reverse side for instructions for completing this application. nn ST E PLA I.D.NUMBER <br /> I. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION.(r�V' 54b <br /> P OPERTYOWNER �! rPROPERTY LOCATION _ <br /> Z7Yv� IML V6W n '/a ''/a, S S T 3�, N, 1 �&W W <br /> PROPERTY OWNER'S MAILING ADORE S U l , �+ S-t, E CITY,STATE ZIPCODE PHONE NUMBER VISION NAME OR CSM NUMBER <br /> V�' Grave �s Nin SSo� b (BIZ Sa- SM Vol. S- fP. /d1 <br /> II. TYPE OF BUILDING: (Check one) o L C NEAR ST ROAD <br /> ❑ State Owned LAGE II R afi RG4� <br /> ❑ Public VI 1 or 2 Fam. Dwelling-#of bedrooms— PAR EL TAX NUMBER( ) <br /> III. BUILDING USE: (If building type is public,check all that apply) b/tf_ a�, 3 55 <br /> 1 ❑ Apt/Condo <br /> 2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Out(ioor Recreational Facility <br /> 3 ❑ Campground 7 ❑ Merchandise: Sales/Repairs 11 ❑ Res aurant/Bar/Dining <br /> 4 ❑ Church/School 8 ❑ Mobile Home Park 12 ❑ Ser ice Station/Car Wash <br /> 5 ❑ Hotel/Motel 9 ❑ Office/Factory 13 ❑ Other: Specify <br /> IV. TYPE OF PERMIT: (Checkonlyone in line A. Check line B if applicable) <br /> A) 1.K New 2. 11 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 /> i <br /> Non-Pressurized Distribution Pressurized Distribution Experimental Other <br /> 11 yJ 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 2.ABSORP.AREA 3.ABSORP.AREA 4. LOADING RATE 5. PERC. RATE 6. SYSTEM ELEV. 7. FINAL GRADE <br /> REO IRED(sq.ft.) PROPOSED(sq.ft.) (Gals/day/sq.ft.) (Min./inch) ELEVATION <br /> ,3 d 45-0 .61 1 q S, Feet Feet <br /> CAPACITY Site <br /> VII. TANK in allons Total #Of Prefab. ! Fiber- Exper. <br /> INFORMATION New xistin Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App <br /> Tanks Tanks _ <br /> strutted <br /> e ti k or Holding Tank t P <br /> Lift Pump Tank/Siphon Chamber <br /> Vlll. RESPONSIBILITY STATEMENT t <br /> I,the undersigned,assume responsibility fort,ristallationof the onsite sewage system shown on the attached pi ans. <br /> Plumber's Name(Print): Plu ber's signature:(N S s) MP/MPRSW No.: Business Phone Number: <br /> k(S 6-ev V S77� <br /> P umbar' Address(Strep(,CIty, tale,Zip Code): ^ `. �Pf <br /> do rr l/r(JU vr— (F`JCSf QIYI_ tll-e„� ! <br /> IX. COUNTY/DEPARTMEN USE ONLY <br /> ❑ DisapprovedSanitary Permit Fee(includes Groundwater Date ssu Elssui!ngAgVnig2nalie(N t pal <br /> �1 ✓'Surcharge F. <br /> / <br /> Approved ❑ Owner Given Initial I.5 jC Jri <br /> Adverse Determination / V+ <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> I <br /> , <br /> I <br /> I <br /> SBD-6398(R.08/93) DISTRIBUTION: Original to County,One Copy To:Safety&Buildings Division,Ow er,Plumber <br />