Laserfiche WebLink
�ILH 0 SANITARY PERMIT APPLICATION <br /> In accord with ILHR 83.05,Wis.Adm.Code COUN <br /> +�O <br /> —Attach complete plans(to the county copy only)for the system,on paper not less than STATE SANITARYPMIT# <br /> //� Lf�� <br /> 8%x 11 inches in size. ❑ Ctleck 1f aloo previous application <br /> —See reverse side for Instructions for completing this application. STATE PLAN I.D.NUMBER <br /> 1. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION. <br /> PROPERTY OWNER PROPERTY LOCATION <br /> / - '/s Ya,S 34 T Yo , N, R / (or W <br /> PROPERTY OWNER'S MAILING ADDRESS LOT# BLOCK# <br /> 1273 ov <br /> CITY,STATE /14;IV ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER <br /> A LL Iry z ,2 )L/23-Off ao5 . 6�v't, <br /> II, PE OF BUIL heck One CITY NEAREST ROAD <br /> State Owned VILLAGE <br /> S WILL oq <br /> ❑ Pub c 1 or Fam. Dwellingof bedroomPARCEL TAX NUMBER(S) <br /> III. BUILDING E: Ilding type is public,check all that apply) <br /> X10 1 g , q � 36 r.. C) <br /> 1 11Apt/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 Hnse< <br /> IV. TYPE OF <br /> OF PERMIT: (Check only one in line A. Check line B if applicable) <br /> A) 1. L'1 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 /> 11 [B 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. ORPTIO SYSTEM INFORMATION: <br /> 1. O S PER D 2.ABSORP.AREA 3.A EA 4. LOAD 5. PERC.RATE 6. SYSTEM ELEV. 7. FINAL GRADE <br /> 30© REQUIRED(sq.ft.) <br /> P SED(s ft.) (Gal d-a7/s .1t. (Min./inch) ELEVATION <br /> y/O ♦ / Z3 1 q3,5Feet /OO,O Feet <br /> TAN CAPACITY Site <br /> in allons of Prefab. Fiber- Exper. <br /> INFORMATION New istin Gallons Tanks Manufacturer's Name oncret Con- Steel glass Plastic A <br /> Tanks Tanks structed pp' <br /> Septic Tank or HoldingTank 00 Soo / U V <br /> Lia Pump Tank/Siphon Chamber <br /> Vlll. RESPONSIBILITY STATEMENT <br /> I,the undersigned,assume responsibility for installation of the onsite sewage system shown on the attached plans. <br /> Plumber's me(Print): Plumb rignature:(No Stam pa) PRSW No.: Business Phone Number: <br /> m ddreea treat,City,State,Zip Co _ <br /> I . COUNTY/DEP RTMENT USE ONLY <br /> Lj Disapproved Sanitary Permit Fee(ImIudes Groundwater aessu Issuin nt Si lure ps) <br /> ❑Approved ❑ Owner Given Initial Surcharge Fee) <br /> i <br /> Adverse Determination <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPP OVAL: <br /> X_ ze <br /> 61e- <br /> SBD-6398(formerly Plb-67)(R.11/88) DISTRIBUTION: Original to County,One Copy To:Safety&Buildings Division,Owner,Plumber <br />