Laserfiche WebLink
SANITARY PERMIT APPLICATION COUNTY&r, <br /> DILHR In accord with ILHR 83.05,Wis.Adm.Code <br /> STATE SANITARY PERMIT#)SSoo� <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than <br /> 8'%x 11 inches in size. ❑ Check if revisiod 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 PROPERTY LOCATION <br /> Lea Len eP_ NE '/. '/.,S 33 T 41 , N, R 16 E (or) <br /> PROPERTY OWNER'S MAILING ADDRESS LOT# BLOCK# <br /> 7619 Round Lake Drive 2 <br /> CITY,STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER <br /> Danbury, (uI 54830 715 656-3027 CSM Vol. 6, Pg. 95 U OV'ItI Lc_�T0 CITY <br /> 3 <br /> II. TYPE OF BUILDING: (Check one) ❑ State Owned VILLAGE NEAREST ROAD <br /> Swiee Round Lake Drive <br /> ❑ Public X❑1 or 2 Fam. Dwelling-#of bedrooms 2 PAR AX NUMERIbi <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 B if applicable) <br /> A) 1. ❑ New 2. LX] 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 ❑ 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 DAI 2.ABSORP.AREA3.ABSORP.AREA 14. LOADING RATE 15. PERC.RATE 6. SYSTEM ELEV. 17. FINAL GRADE <br /> REQUIRED(sq.ff.) PROPOSED(sq.ft.) (Gals/day/sq.ft.) (Min./inch) ELEVATION <br /> 300 480 1 480 .63 3 95.7 Feet 98.5 Feet <br /> VII. TANK CAPACIqa <br /> Site <br /> in alloTotal #of Prefab. Fiber- Exper. <br /> INFORMATION New Gs Tanks anuacurer's Name oncret Con- Steel glass PlasticApp <br /> Tanks Tstrutted <br /> Se ticTankor Holdino Tank 150 1750 1 1 <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's7 Signal ur IN Stamps) MP/MPRSW No.: Business Phone Number: <br /> PJade Ru4ahaPxn (ti 3361 715 349-7286 <br /> Plumber's Address(Street,City,State,Zip Code): <br /> P.U. Box 514 24702 Lind Road Siuen, W1 54872 <br /> IX. C.OUNTYIDEPARTMENT USE ONLY <br /> E] Disapproved I sanitary Permit Fee(Includes Groundwater a e saue Iss Agent Sign a(No Stamps) <br /> Surcharge Feel <br /> pproved F-1OwnerGiven Initial �} ' ` HT1 <br /> AdverseDetermination -i1 O=L i�✓/L <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 />