Laserfiche WebLink
_ . ILHR SANITARY PERMIT APPLICATION COUNTY <br /> ` <br /> In accord with ILHR 83.05,Wis.Adm.Codey�— <br /> STATE SANITARY P MIT# I''5 ZSS j <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than (i U71P3 <br /> 8'%x 11 inches in size. ❑ Check if revision to 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 P OPER 0 ATION <br /> .� N I '%, S Z T o, N, R , E (o W <br /> PROP RTY OWNER'S�tLING AD RE L T# BLOCK# <br /> CITY,STATE VVI` ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMB <br /> �njRgplpc), MN 5543 -2 c 5rn U l . <br /> CITYNEAREST RO��AD r �K <br /> II. TYPE OF BUILDING: (Check one) ❑ State Owned l7 VILLAGE <br /> C IL Ih Ca L <br /> ❑ Public ®1 or 2 Fam.Dwelling-#of bedroomsZ <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. ❑ 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 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 PE7 2.ABSORP.AREA 13.ABSORP.AREA 14. LOADING RATE 5. FERC.RATE 6. SYSTEM ELEV. 7. FINAL GRADE <br /> REOU REyD1(sq.ft.) PROPOSED(sq.ft.) (Gals/day/sq.ft.) (Min./inch) '1 ELEVATION <br /> C �}3Z „ b-1 3 �. 1 Feet %,5 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 /> Septic Tank or Holdin Tank Q <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:(No Stamps) MP/MPRSWNo.: Business Phone Number: <br /> RODERICKqQ W <br /> lumber's Address(Stre t,City state,Zip Code): <br /> 2T? o � 4 <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> r-t�/' Disapproved Sanitary Permit Fee(Includes Groundwater a e Issuedis i Agent ature(No Stamps) <br /> L`)"Approved ❑ Owner Given Initial \O< �roner9e Feel Lt <br /> Adverse r in �.� 1 \r��a <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(formerly Plb-67)(R.11/88) DISTRIBUTION: Original to County,One Copy To:Safety&Buildings Division,Owner,Plumber <br />