Laserfiche WebLink
SANITARY PERMIT APPLICATION <br /> In accord with ILHR 83.05,Wis.Adm.Code couNTY�urn� <br /> STA ESANITA PERMIT <br /> —Attach complete plans(to the county copy only)for the system,on paper not less than 6STI d <br /> 8'h x 11 inches in size. ❑ heck if re ion[o previous application <br /> —See reverse side for Instructions for completing this application. STA E PLAN I.D.NUMBER <br /> I. APPLICANT INFORMATION—PLEASE PRINT ALL INFORMATION. �5 PROPERTY OWNER PROPERTY LOCATION <br /> V}aI1F $ET4►4 5r Ya �'/a,S 60 T39N, R I E (or W <br /> PROPERTY OWNER'S MAILING ADDRESS LOT# BLOC # <br /> 7(0.1(o GA . Rn . !F�- I �. <br /> CITY,STATE I ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER <br /> 4EOST'Eig5 S93 It Ej CITY <br /> It. TYPE OF BUILDING: (Check one) ❑ State Owned VILLAGE NEAR ST ROAD <br /> ��II DN Co Rn- K <br /> ❑ Public El 1 or 2 Fam.Dwelling—#of bedrooms�— PA EL AX NUMB R(S) <br /> III. BUILDING USE: (If building type is public,check all that apply) I — 3303-01— <br /> 1 ❑ Apt/Condo <br /> 2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Out(ioor Recreational Facility <br /> 3 ❑ Campground 7 ❑ Merchandise: Sales/Repairs 11 ❑ Res aurant/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 /> 11 ❑ Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41Holding Tank <br /> 12 ❑ Seepage Trench 22 ❑ In-Ground 42-5 Pit Privy <br /> 13 ❑ Seepage Pit Pressure 43 ❑ Vault Privy <br /> 14 ❑ System-In-Fill <br /> VI. ABSORPTION SYSTEM INFORMATION: <br /> 1.GALLONS PER 7 2.ABSORP.AREA 3.ABSORP.AREA 4. LOADING RATE 5. PERC.RATE 6. SYSTEM ELEV. 7. FINAL GRADE <br /> REQUIRED(sq.ft.) PROPOSED(sq.ft.) (Gals/day/sq.ft.) (Min./inch) ELEVATION <br /> 3 D o r — Feet Feet <br /> VII. TANK CAPACITY Site <br /> in allons Total #oi Prefab. Fiber- Exper. <br /> INFORMATION New xistin Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App <br /> Tanks Tanks strutted <br /> Septic Tank or HoldingTank O <br /> Lift Pum Tank/Siphon 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): Plumber's Signature:(No St ps) MP/MPRSW No.: But Phone Number: <br /> 2n o;X:1 3426 /S 1-6- g1S1 <br /> Plumber's Address(Street,City,State,Zip Code): <br /> 2 60 NwX 35 W9135M< WL S481 <br /> IX COUNTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved Sanitary Permit Fee(Includes Groundwater a e ssue Iss ng nt Sign iture(No Stamps) <br /> Surcharge Fee) <br /> Approved ❑ owner Given Initial I G,}, <br /> Adverse Determination JV <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(R.08/93) DISTRIBUTION: Original to County,One Copy To:Safety B Buildings Division,Ow er,Plumber <br />