Laserfiche WebLink
SANITARY PERMIT APPLICATION <br /> 75ILHR COUNTY <br /> e� m" <br /> In accord with ILHR 83.05,Wis.Adm.Code <br /> STATESANIT YPERMIT#15i2/_/ <br /> –Attach complete plans(to the county copy only)for the system,on paper not less than ❑ /�JG�� dK'y/ <br /> 8%x 11 inches in size. C L if rev Ion 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 POP PITY LOC TION <br /> MVV' d '/a /a,S T N, R E (or W <br /> PROPERTY OWNER'S MAILING ADDRESS tOT ALOCK# <br /> DN)q A119 , <br /> CITY STATE ZIP C DE PHONE UMBER <br /> &L JI IS 0 63 <br /> DU `�- LcF6 _47 <br /> If. TYPE OF BUILDING: (Check one) ❑ State Owned viLTMI AGE NF�RE ROA , L <br /> ❑ Public ,X 1 or 2 Fam. Dwelling,#of bedrooms NFICIEL TAX N M ( w �/\ <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. ❑ New 2. Replacement 3. ElReplacement 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 ❑ 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 14. LOADING RATE 5. PERC.RATE 6. SYSTEM ELEV. 7. FINAL GRADE <br /> Q REQUIRED(sq.ft.) PROPOSED(sq.ft.) (Gals/da /sq.ft.) (Min./inch) yn ELEVATION <br /> 3 / Feet Feet <br /> VII. TANK CAPACITY <br /> in allons Total Site <br /> INFORMATION #of Manufacturer's Name Prefab. Con- Steel Fiber- Plastic Exper. <br /> New istin Gallons Tanks oncret strutted glass App. <br /> Tanks Tanks <br /> Septic Tank or Holdina Tank N001 — <br /> Lift Pump Tank/Siphon Chamber,221- 1 -S001 <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 Stamp) MP/MPRSW No.: Business Phone Number: <br /> lumber's Add (Street'.ity,State,Zip C,od � P)/ OW <br /> IX. OUNTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved SanI ry Permit Fee(Includes Groundwater Date IssuedIssuing Ag tSign urs mps) <br /> LL, 10_ V. Surcharge Fee) ,`—l^ <br /> Approved ❑ Owner Given Initial —44JY. l/ 7l"Jl [Ij ✓JI (`/ <br /> Adve rmination I <br /> X. NDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(formerly Plb-67)(R.11/88) DISTRIBUTION: Original to County,One Copy To:Safety 8 Buildings Division,Owner,Plumber <br />