Laserfiche WebLink
�,. „ SANITARY PERMIT APPLICATION <br /> vA�I41R In accord with ILHR 83.05,Wis.Adm.Code COUNTY <br /> C�S�I 2 <br /> STAT SANITARY IT# <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than ❑J1g�1 PERM"ql y <br /> 8'% /sion 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 PROPE <br /> RTY <br /> Tip mpsot-� ( S l� TqO , N, R b E (orPROPERTY OWNER'S MAILING ADDRESS LOT# BLOCK# <br /> T , }h sr- sE CITY,STATE ZIPCODE PHONE NUMBER SUBDR CSM NUMBER <br /> LS MlJ SS toIZ o �;^ (q <br /> It. TYPE OF BUILDING: (Check one) ❑State Owned VILLAGE 1 CITY NEAREST ROAD <br /> i� :©akLAtJP Rn Uc - RD. <br /> [] Public IaJ.t ort Fam. Dwelling-#of bedrooms P CELTAx NUMBER(s) <br /> 111. BUILDING USE: (If building type is public,check all that apply) �- �0 <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) 1.1< 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 /> 11Seepage Bed 21 ❑ Mound 30 ElSpecify Type 41 ElHolding Tank <br /> 12 N 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 /> cT <br /> REQUIRED(sq.ft.) PROPOSED(sq.ft.) (Gals/day/sq.ft.) (Min./inch) /� ELEVATION <br /> LtJV SD 75-D . (0 �- `� • 3 Feet . D Feet <br /> VII. TANK CAPACITY Site <br /> in allons Total #of Prefab. Fiber- Exper. <br /> INFORMATION New istin Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App <br /> Tanks Tanks strutted <br /> Septic Tank or Holding Tank O "— 0O <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/MPRSW No.: Business Phone Number: <br /> IL}4 n o k/A/5 3yZ6 <br /> P 7/5 gbb- lV/S� <br /> Plumber's Address(street,City,State,Zip Code <br /> o t4wg 5s- vilks5reK 0,W . sgns <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved I Sanitary Permit Fee(Includes Groundwatera e ssue Issuin Agent Signature(No Stam s) <br /> Approved El Owner Given Initial surcharge Fee) �y/ <br /> Adverse Determination «' -��-� 1 <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(R.08/93) DISTRIBUTION: Original to County,One Copy To:Safety&Buildings Division,Owner,Plumber <br />