Laserfiche WebLink
SANITARY PERMIT APPLICATION COUNTY <br /> DILHR <br /> t=.e �•..��.� In accord with ILHR 83.05,Wis.Adm. Code r� <br /> STATE SANITARY PERMIT# i3'aS Z.l <br /> –Attach complete plans(to the county copy only)for the system,on paper not less than >z l H(h 7 (.f <br /> 8'%x 11 inches in size. ❑ Check if revision 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 /> S lV LJ '/a S W %, S T W, N, R /S– E(o W <br /> PROPERTY OWNER'S MAILING ADDRESS LOT# / BLOCK <br /> S^ a. Z_ f c /Q 1 <br /> CITY,STATE ZIP CODEPHONE NUMBER SUBDIVISION NAME OR CSM NUMBER <br /> ati ^Yf'3e SA+ vat=EST <br /> U /1 / 3 / 50 <br /> 0 CITY It. TYPE BUILDING: (Check one) ❑ State Owned VILLAGE ROAD <br /> SL <br /> ❑ Public Q1 or 2 Fam. Dwelling–#of bedrooms LAX NUM ( ) <br /> Ill. 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. ❑ 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 /> 11Seepage Bed 21 El Mound 30 ❑ Specify Type 41 El 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 2.ABSORP.AREA 13.ABSORP.AREA 14. LOADING RATE 5. PER'.RATE 6. SYSTEM ELEV. 7. FINAL GRADE <br /> REQUIRED(sq.ft.) PROPOSED(aq.ft.) (Gals/day/sq.ft.) (Mindinch) G ELEVATION <br /> 3 (� Y/O 3 - G C f � Feet / �Z Feet <br /> VII. TANK CAPACITY I Site <br /> in gallons Total #of Prefab. Fiber- Exper. <br /> INFORMATION New istin Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App <br /> Tanks I Tanks 1 structed <br /> Septic Tank or Holdin Tank S H''I <br /> Lift Pum Tank/ l 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): PI er's Si nature:(No Stamps) MP/MPRSW No.: Business Phone Number: <br /> /To t�icI <br /> Plumber' Ad resa(Street,City,State,Zip Code): ,p <br /> IX. COUNTYIDEPARTMENT USE ONLY <br /> Disapproved I Sanitary Permit Fee(Includes Groundwater Date Issued gnat (No Stamps) <br /> ApprovedSurcharge Fee) <br /> Owner Given Initial 'O/" � ��-.-� •S <br /> AdverseDetermination J <br /> X. CONDITIONS OF APPROVALIREASONS FOR DISAPPROVAL: <br /> SBD-6398(formerly Plb-67)(R.11/98) DISTRIBUTION: Original to County,One Copy To:Safety&Buildings Division,Owner,Plumber <br />