Laserfiche WebLink
MTDq_71LLL,,HR SANITARY PERMIT APPLICATION COUNTY <br /> In accord with ILHR 83.05,Wis.Adm.Code <br /> STA ANITARY ERMIT#/5/437 <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than / <br /> 834 x 11 inches in size. ❑ 9/ci)3 topreviousapplicetion <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 9WNER PROPERTY LOCATION <br /> Qi <br /> ��h�tQ Vl "', uE'/s 1/4,S�CJ TYtj N, R / W <br /> PROPERTY OWNER'S MAILING ADDRESS LOT# BLOCK# <br /> 3ct <br /> CITY,STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER <br /> S�-F S�F4�o �- zF /y <br /> II. TYPE OF BUILDING: (Check one CITY NEAREST ROA//D <br /> ❑State Owned VILLAGE i� (<H I oitGN <br /> ❑ Public X 1 or 2 Fam.Dwelling-#of bedrooms L Ax ( ) <br /> III. BUILDING USE: (If building type is public,check all that apply) �O-43ac)—OL —Cm <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: (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 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 61 2.ABSORP.AREA 13.ABSORP.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) G�/ LEVATION <br /> �a a lv 7 3-3-3 ((. Feet Feet <br /> VII. TANK CAPACITY Site <br /> in allons Total #of Prefab. Fiber- Exper. <br /> INFORMATION New istin Gallons Tanks Manufacturer's Name oncrete Con- Steel glass Plastic App <br /> Tanks Tanks strutted <br /> e tic TaoPor Holdino Tank <br /> Lift Pump Tank/Siphon Chamber <br /> VIII. RESPONSIBILITY STATEMENT <br /> I,the undersigned,assume responsibility for i stallation of the onsite sewage system shown on the attached plans. <br /> Plumber's Name(Print): PlurAer's Si ature:( oS mps) MP/MPRSWNo.: Business Phone Number: <br /> e�S t- 1— !tit 5� 7/ <br /> lumber's Address(Street, ily, le,Zip Code): <br /> Wz6s4r-4 LL-4 2- 2-92> <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑ DisapprovedSanitary Permit Fee(Includes surcharge Fee)Groundwater Date IssuedIssuing gent Signature(No Stamps) <br /> Approved El Owner Given Initial 531 71 YY v <br /> Adverse D t rminetion ki� OP�lls, 00 I <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 />