Laserfiche WebLink
77— SANITARY PERMIT APPLICATION <br /> DILHR In accord with ILHR 83.05,Wis.Adm. Code couNTv <br /> STATPANITAPERMIT#)/I,D/�.// <br /> —Attach complete plans(to the county copy only)for the system,on paper not less than El/ j� G , 7 <br /> 8'6 x 11 inches in size. ack if re ton 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 PROPERTY LOCATION <br /> '/4, S T b, N, R Co E (or) <br /> PROPERTY OWNER'S MAILING ADDRESS LOT# BLOCK# <br /> IILDA-Kt N <br /> CITY,STATE I ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER <br /> h o,j r 0 ?M�JDIJW (uc(L N < <br /> If. TYPE OF BUILDING: one)Check El CITY NEAREST ROAD <br /> ( ❑ State Owned VILLAGE4 LA OF: 0A (r L <br /> ❑ Public 1 or 2 Fam.Dwelling-#of bedrooms Z— PARCEL AX NUM <br /> III. BUILDING USE: (If building type is public,check all that apply) <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 XNew 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5.❑ Repair of an <br /> /^ <br /> System System Tank Only Existing System / Existing System <br /> B) I LA Sanitary Permit was previously issued. Permit# �l in�qui Date Issued / Ro <br /> ,�ff <br /> V. TYPE OF SYSTEM: (Check only one) <br /> Non-Pressurized Distribution Pressurized Distribution Experimental Other <br /> 11 Seepage Bed 21 ElMound 30 ❑ Specify Type 41 El Holding Tank <br /> 1 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 91 2.ABSORP.AREA 13.ABSORP.AREA 14. LOADINGRATE 5. PERC.RATE 16. SYSTEM ELEV. 17. GRADE <br /> REQUIRED(sq.ft.) PROPOSED(sq.ft.) (Gals/day/sq.ft.) (Min./inch) ELEVATION <br /> o '-B-2, „ (n<, 3 , Feet 100,6 Feet <br /> VII. TANK CAPACITY Site <br /> in allons Total #of Prefab. Fiber- Exper. <br /> INFORMATION New istin Gallons Tanks Manufacturer's Name oncrete Con- Steel glass Plastic App <br /> Tanks Tanks strutted <br /> Se tic Tank or Holdin Tank <br /> Lift 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:(14oS mps) MP/MPRSW No.: Business Phone Number: <br /> 06KI0C Pklf'S Ta,,j Z) cis IS 6 5 <br /> Plumber's Address(Street,City,State,zip Codd)* <br /> 2"I"i v N�3Str_R L.w <br /> IX. IDOUNTYIDEPARTMENT USE ONLY <br /> ❑ Disapproved Sanitary Permit Fee(includes Groundwater Date Issued Is Ing gent Signa (No Stamps) <br /> /�r Surcharge Feel ^1 <br /> Approved ❑ Owner Given Initial /V�.Io � -aci_9 <br /> Adverse Determinatio (V=.1 ' <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: y' <br /> j <br /> SBD-6398(formerly Plb-67)(R.11/88) DISTRIBUTION: Original to County,One Copy To:Safety&Buildings Division,Owner,Plumber <br />