Laserfiche WebLink
DILHR SANITARY PERMIT APPLICATION COUNTY <br /> In accord with ILHR 83.05,Wis.Adm.Code <br /> STATE SANITARY PERMIT# <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than (/�4 <br /> 8'%x 11 inches in size. 1:1Cheek If revl 4previous 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 OWNP PROPERTY LOCATION <br /> NW'/a A&,N4,S l3 T '�{e , N, R /S E (or <br /> PROPERTY OWNER'S MAILING ADDRESS LOT# BLOCK# <br /> !a�/ri/�/h�7C l�A3tl 63 <br /> A174- <br /> Cl <br /> u� <br /> CI ,STATE ZIP CODE / PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER <br /> CITY : NEAREST ROAD <br /> If. TYPE OF BUILDING: (Check one) ❑ State Owned VILLAGE <br /> ❑ Public %1 or 2 Fam. Dwelling-#of bedrooms a PA EL A OMB ) , <br /> III. BUILDING USE: (If building type is public,check all that apply) l -1 ) 75-1 1 —3oD <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. TYPPEOF PERMIT: (Check only one in line A. Check line B if applicable) <br /> A) 1. KNew 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 '59�Zeepage 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 12.ABSORP.AREA 13.ABSORP.AREA 14. LOADING RATE 15. PERC.RATE 16. SYSTEM ELEV. 17. FINAL GRADE <br /> REQUIRED(sq.ft.) PROPOSED(sq.ft.) (Gals/day/sq.ft.) (Min./' ch) / r. ELEVATION <br /> e7111-1 <br /> �� fd 7/1 .7 C - Feet 7 Feet <br /> VII. TANK CAPACITY Site <br /> in allons Total #of Prefab. Fiber- Exper. <br /> INFORMATION New iss Gallons Tanka Manufacturer's Name Prefab. Con- Steel glass Plastic App <br /> Tanks Tanks strutted <br /> Septic Tank or Holdin Tank /'�' "1K' <br /> Lift Pum Tank/Si hon Chamber <br /> Vlll. 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.§1amps MPIMPRSW No.: Business Phone Number: <br /> E - XkL I r 3o�a �,- -moo <br /> Plumber's Address(street,City,state,Zip Code): <br /> X 7- S 16 0 5'`l� i �J/ _ S%/8-�3 d <br /> COUNTY/DEPARTMENT USE ONLY <br /> Disapproved Sani, ry Permit Fee(Includes Groundwater ate Surcharge Fee) <br /> Issue Is s n Agent Sig re(No Stamps) <br /> Approved ❑ Owner Given Initial /U�IJ\ �-� - <br /> Adverse Determination <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 />