Laserfiche WebLink
SANITARY PERMIT APPLICATION <br /> DILHR In accord with ILHR 83.05,Wis.Adm.Code CDt,Nr <br /> hu r <br /> •��• STATE NITA ERMIT#/ � ' <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than NITA 3 <br /> 8'%x 11 inches in size. ❑ Check if revision o previous application <br /> -See reverse side for instructions for Completing this application. STATE PLAN I.D.N6MBER <br /> I. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION. ��- <br /> PROPERTY OWNER PROPERTY LOCATION // <br /> ! [� ( 4 ''/4, S T N, R ,b E(or W <br /> PROP TY OWNER'S MAILING ADDRESS LOT# BLOCK# <br /> CITY,STAT ZIP DE PHONE NUMBER <br /> _ Ego 3 4! o c <br /> Lj CITY a N REST ROAD <br /> If. TYPE OF BUILDTG: (Check one) State Owned VILLAGE MI .V NeREST X <br /> ❑ Public 1 or 2 Fam.Dwelling-#of bedrooms AX N1UMM:K(S) O <br /> III. BUILDING USE: (If building type is public,check all that apply) �S- 3,j -O - <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 1ql 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 12.ABSORP.AREA 3.ABSORP.AREA 4. LOADING RATE 5. PERC.RATE 6. SYSTEM ELEV. 7. FINAL GRADE <br /> REQUIRED(sq.ft.) PROPO�S7ED(sq.tt.) (Gals/day/sq.ft.) (Min./inch) ELEVATION <br /> 31)-5 1 , 2 Feet + Feet <br /> 14 2L VII. TANK CAPACITY Site <br /> in allons Total #otPrefab. Fiber- Exper. <br /> INFORMATION New xistin Gallons Tanks Manufacturer's Name oncrete Con- Steel glass Plastic App <br /> Tanks an structed <br /> Septic Tank or Holdina Tank 100o <br /> Lift Pump Tank/SI hon 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:( o Stamps) MP/MPRSW No.: Business Phone Number: <br /> :Kjapikp o K)nts Z6 1 fs 2" !S <br /> PiUmber's Address(Street,City,State,Zip Co ): <br /> 2-77(,0 Hwy 3E 0f9silEe . uJi- <br /> IXj COUNTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved Sanitary Permit Fee(Includes Groundwater a e ssue Issuing Ag ignat a(No pal <br /> kApproved Surcharge Fee)❑ Owner Given Initial d}/�0 /�0 <br /> Adverse Determination <br /> --NN Vii lJl�' / a <br /> X. CONDITIONS OF APPROVALIREASONS FOR DISAPPROVAL: <br /> SBD-6398(formerly Plb67)(R.11/88) DISTRIBUTION: Original to County,One Copy To:Safety&Buildings Division,Owner,Plumber <br />