Laserfiche WebLink
SANITARY PERMIT APPLICATION <br /> 7DILHR In accord with ILHR 83.05,Wis.Adm.Code COUNTY <br /> �- <br /> �• STATE SANITAR PERMIT# <br /> -Attach complete plans(to a county copy only)for the system,on paper not less than CI ' - . �\�7> <br /> 8'%x 11 inches in size. ❑ Check if revision to previous application <br /> wee reverse side for instru tions for completing this application. STATE PLAN I.D.NUMBER <br /> 1. APPLICANT INFORMATI N-PLEASE PRINT ALL INFORMATION. <br /> PROPERTY OWNER PROPERTY LOCATION <br /> 4 Lc- I?AKDLk J '/4 '/4, S2-5 T`f I , N, R 17 E(o W <br /> PROPERTY OWNER'S MAILING A[DRESS LOT# BLOCK# <br /> 30301 ST. CKOlx 1V-. <br /> CITY,STATEIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER <br /> Ani W1 . X30 <br /> 11. TYPE O BUILDING: (C ck one) El State Owned VILLAGE S�),CZ [—NEARESTROAD <br /> Q <br /> ❑ Public 91 or 2 am. Dwellings of bedrooms? ( ) <br /> III. BUILDING USE: (If build ng 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 ❑ RestauranttBar/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: (Cheek 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 Distribu ion Pressurized Distribution Experimental Other <br /> 11 19 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 SYSTEMINFORMATION: <br /> 1.GALLONS PER DAI 2.A SORP.AREA 13.ABSORP.AREA 14. LOADING RATE 5. PERC.RATE 6. SYSTEM ELEV. 7. FINAL GRADE <br /> REQ IRED(sq.ft.) PROPOSED(sq.ft.) (Gels/day/sq.ft.) (Min./inch) ELEVATION <br /> ,30o go '4BO .(OZ 93.3 Feet 95•$ Feet <br /> CAPACITY <br /> VII. TANK Site <br /> in allons Total #oT Prefab. Fiber- Expp. <br /> INFORMATION New Istin Gallons Tanks Manufacturer's Name oncret Con- Steel glass Plastic App <br /> anka Tanks strutted <br /> Septic Tank or Holding Tank i <br /> Lift Pump 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 Stamps) MP/MPRSW No.: Business Phone Number: -7 <br /> Ird1A(1D 0 1N ,3`174 7/S �6- Lit( / <br /> umber's Address(Street,City,S te,zip Code): <br /> 2116 0 qw 35 W 68STEcz l/J I - _"5 993 <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> Disapproved Sanitary Permit Fee(Includes Groundwater Datessu Issuin gent SignatueNoS mps) <br /> Approved ❑ Owner Giver Initial _Surcharge Fee) D• ) <br /> A v D to rmination CA <br /> X. CONDITIONS OF APPRC VALIREASONS FOR DISAPPROVAL: <br /> SBD-6398(formerly PRIBUTION: Original to County,One Copy To:Safety&Buildings Division,Owner,Plumber <br />