Laserfiche WebLink
DILIR SANITARY PERMIT APPLICATION COUNTY <br /> In accord with ILHR 83.05,Wis.Adm.Code <br /> �k rReY <br /> STATE MNITARY PERMIT#',]n la <br /> –Attach complete plans(tc the county copy only)for the system,on paper not less than C 193&\ <br /> Vs <br /> 8%x 11 inches in size. ❑ Check It revisigA to previous applimtion <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 /> `5✓.-���/LLAW Or2el E '/a i!5* '/a,S T 3 S N, R W <br /> PROPER O ER'S MAILING QADDRESS� � LOT# BLOCK k <br /> CITY, <br /> OOI`TY3ST 7TE t cZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER <br /> k'elf� s �S CS,�3 V, ' Fjov [o;s 9 <br /> 11. TYPE OF BUILDING: ( heck one) CITY NEAREST ROAD <br /> IQ l ❑State Owned 0 VILLAGE S ^ 1_ �At <br /> ❑ Public Ipl 1 or Fam. Dwelling of bedrooms A I 7Y l <br /> III. BUILDING USE: (If building type is public,check all that apply) DS_ a'IFS- 0/' ---70D <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. N Replacement 3. ❑Replacement of 4. ❑ Reconnection of 5.❑ Repair of an <br /> System System Tank Only Existing System Existing System <br /> B) ❑ A Sanitary Perrr it was previously issued. Permit# — Date Issued <br /> V. TYPE OF SYSTEM: (C eck only one) <br /> Non-Pressurized Distribution Pressurized Distribution Experimental Other <br /> 11 RSeepageBed 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 j2.ABSORP.AREA j3.ABSORP.AREA 14. LOADINGRATE 15. PERC.RATE 16. SYSTEMELEV. 7. FINAL GRADE <br /> R OUIRED(sq.ft.) I PROPOSED(sq.ft.) I (Gals/day/sq.ft.) (Min./inch) ELEVATION <br /> QI Vso 1 16" ' Cr '/3,4P7/3.4P Feet <br /> VII. TANK CAPACITY Site <br /> in allons Total #of Prefab. Fiber- Exper. <br /> INFORMATION New Istin Gallons Tanks Manufacturer's Name oncret Con- Steel glass Plastic App <br /> Tanks Tanks strutted <br /> tic Ta or Holdin Tank t <br /> Litt Pump Tank/Siphon Chambe <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): Plu is Signature.(No mpa) M'^P,/MPRSW No.: Business Phone Number:y <br /> Plumber's Address(Street,C_i State,Zip Code): <br /> C (o Je <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ED Disappro d Sanitary Permit as includes groundwater a e ssue Issui em Si n ture(No Stamps) <br /> Approharge Fag) <br /> ved Downer Gi an Initial f�(�" i'�T\ <br /> A vers rminati (( L.JLl Surc <br /> X. CONDITIONS OF APPI 1OVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6396(formerly Plb-67)(R.1 /88) DISTRIBUTION: Original to County,One Copy To:Safety&Buildings Division,Owner,Plumber <br />