Laserfiche WebLink
SANITARY PERMIT APPLICATION <br /> In accord with ILHR 83.05,Wis.Adm.Code couNTYn <br /> D1LHR NIr� <br /> STATESANITARY PERMIT#oa31 <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than ) j <br /> 8'%x 11 inches in size. ❑ Check If revision 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 PROPERTY LOCATION l' <br /> % %,S T O , N, R (-1 E (o <br /> PROPERTY OWNER'S MAILING ADDRESS LOT# BLOCK If <br /> C V- N <br /> CITY,STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR M`NU BEF ., ,, / <br /> RoDY.t.. rJ ARK. a C F{ �/ V <br /> 11. TYPE OF BUILDING: (Check one CITY N REST ROAD '� 11�� <br /> ❑State Owned VILLAGE OM r-�+ • WA14 <br /> � <br /> l or 2 Fam.Dwelling-#of bedrooms A Ax <br /> El Publia / <br /> NQF <br /> 111. 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 Bit applicable) <br /> A) 1New 2. ElReplacement 3. El 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 /> 1SeepageBed 21 ElMound 30 ❑ Specify Type 41 ❑ Holding Tank <br /> 1 ❑ 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.AS )RP.AREA 13.AS RP.AREA 14. LOADING RATE 5. PERC.RATE 6. SYSTEM ELEV. 17. FINAL GRADE <br /> REQUIRED(sq.ft.) PROPOSED(sq.ft.) (Gals/day/sq.ft.) (Min./inch) 1117-Z <br /> ELEVATION <br /> 300 1 (02 3 Feet I()0_0 Feet <br /> VII. TANK CAPACITY ISite <br /> in allons Total I Prefab. Fiber- Exper. <br /> INFORMATION New istin Gallons Tanks Manufacturer's Name oncret Con- Steel glass Plastic App <br /> Tanks Tanks strutted <br /> Septic Tank or Holding Tank <br /> Lift Pump Tank/Siphon 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 mps) MP/MPRSW No.: Business Phone Number: <br /> I(*A9p ROP910 I &W (U <br /> Plumber's Address(Street,City,State,Zip Code): <br /> T 17(,o 3,15' ' SW, <br /> IX. COUNTYIDEPARTMENT USE ONLY <br /> ❑ Disapproved SanitaryPermit as(Includes Groundwater Ja e Issued Issuin Agent na tamps) <br /> I��•�surcharge Fes) <br /> Approved ❑ owner Given Initial <br /> Adverse Determination <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-8398(formerly Plb-67)R.11/88) DISTRIBUTION: Original to County,One Copy To:Safety 8 Buildings Division,Owner,Plumber <br />