Laserfiche WebLink
S _ILHR SANITARY PERMIT APPLICATION N <br /> In accord with ILHR 83.05,Wis.Adm.Code �p�ouNu rYtd ., <br /> ��- STATE SA�IITAR PERMIT#15,/3/f <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than <br /> 8%x 11 inches in size. ❑ Chelk if revisl to previous application <br /> -See reverse side for Instructions for Completing this application. AgTE PLAN I.D.NUMBER <br /> I. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION. O .S <br /> P OPE TY O ER PROPERTY LOCATION q} <br /> 1C 2{- (Ll '/aNWya, S T3N, R l �J-It(>7r W <br /> PROPERTY OWNER'S MAILING AD9qRESS1 LOT# BLOCK# <br /> 9-C) 7 30 g t h nS�4 kt 21 0 <br /> TY,STATE zip CoD PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER <br /> � bey w, s�fs�Eo �� a37 <br /> CITY NEAREST ROAD <br /> IL TYPE OF BUILDING: (Check one) <br /> ❑ State Owned VILLAGE: �?eyvpy� 014 <br /> ElPublic %1 or 2 Fam. DweI11ng-#of bedrooms 3 RYO UMBER(S) 1 <br /> 111. BUILDING USE: (If building type is public,check all that apply) , �/O'- �3Ef ' 0��_3co <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. TYPEOFPERMIT: (Check only one in line A. Check line B if applicable) <br /> A) 1. Id 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 X Mound 30 ❑ Specify Type 41 ❑ Holding Tank <br /> 12 11 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 j2.ABSORP.AREA 13.ABSORP.AREA 14. LOADINGRATE 15. PERC.RATE 6. SYSTEM ELEV. T FINAL GRADE <br /> crn-7� REQUIRED(sq.ft.) PROPOSED(sq.ft.) (Gals/day/sq.ft.) (Min./inch) �ELEVATION <br /> 377 -J- 3 • Cl Feet /d.�-S Feet <br /> VII. TANK CAPACITY Site <br /> in gallons Total #of Prefab. Fiber- Exper. <br /> INFORMATION New istin Gallons Tanks Manufacturer's Name oncret Con- Steel glass Plastic App <br /> Tanks Tanks <br /> structed <br /> ti Holdin Tank D60 <br /> i Pum T SI hon Chamber (00 d <br /> Vlll. RESPONSIBILITY STATEMENT <br /> 1,the undersigned,assume responsibility for'nstallation of the onsite sewage system shown on the attached plans. <br /> Plumber's Nam (P Int): Plu bar's gnetu e:( Stamps) MP/MPRSW No.: Business Phone Number: <br /> �� _h I— ti� (71 6-ea(* <br /> Plumber's Address(Street,City,State,zip Code: ,) . <br /> 7 �s C "Dg "a (� t <br /> IX. COUNTYIDEPARTMENT USE ONLY <br /> ❑ Disapproved Sanitary Permit as(Includes Groundwater a e ssue Issuing A e lgnqt mps) <br /> Sumharge Fee) <br /> pproved ❑ Owner Given Initial y,f I-7O. 00 <br /> A Determination `!-( V <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 8 Buildings Division,Owner,Plumber <br />