Laserfiche WebLink
SANITARY PERMIT APPLICATION COUNTY 5, <br /> 7DILHR In accord with ILHR 83.05,Wis.Adm.Code <br /> p��• mm STATE SANITARY-PERMIT,\ #I�)��C ' <br /> –Attach complete plans(to the county copy only)for the system,on paper not less than �� 7��o� <br /> 8%x 11 inches in size. ❑ Check If revlel to Drevious 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 /> PROPS9TY OWNER PROPERTY Via,LOCATION q T , N, R S E (O <br /> PROPERTY OWNER'S MAILING ADDRE LOT# BLOCK# <br /> CITY,STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER <br /> Z�JMZZM 40, 5z/'7 6/z 573-29 12Sm VOL <br /> El CITY I NEAREST ROAD <br /> II. TYPE OF BUILDING: (Check one) ❑State Owned VILLAGE : SW L S S rA `9 C L /2 4) . <br /> ❑ Public ❑1 or 2 Fam. Dwelling,#of bedrooms L Ax ER( ) <br /> 111. BUILDING USE: (If building type is public,check all that apply) 0 <br /> 1 ❑ ApVCondo D <br /> 2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility <br /> 3 ❑ Campground 7 ❑ Merchandise: Sales/Repairs 11 ❑ RestauranVBar/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. jX New 2. ❑ Replacement 3. ❑ Replacement of 4. El Reconnection of 5.El 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 1p�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 DAY 12.ABSORP.AREA 3,ABSORP.AREA 14. LOADING RATE 5. PERC.RATE 6. SYSTEM ELEV. 17. FINAL GRADE <br /> REQUIRED(sq.ft.) PROPOSED(sq.ft.) (Gala/day/sq.ft.) (Min./inch) / r , ELEVATION <br /> S 0� (0 f c(C.% �.+ Feet /CJ Feet <br /> VII. TANK CAPACITY Site <br /> in allons Total sof <br /> Prefab. Fiber- Exper. <br /> INFORMATION New istin Gallons Tanks Manufacturer's Name oncret Con- Steel glass Plastic App <br /> Tanks Tanks strutted <br /> Septic Tank or Holdin Tank - <br /> Lift Pump Tank/Siphon Chamber <br /> VIII. RESPONSIBILITY STATEMENT <br /> 1,the undersigned,assume responsibility for installation of the onsite sewage system shown on the attached plans. <br /> Plumber's Name(Print): Plu tura:(No mps) MP/MPRSW No.: Business Phone Number:? <br /> Plumber's Address(Street,City,State,Zip ode): <br /> k7 Z 30 Y2(,) �f]/ ' ( CO/11 <br /> Sof ) <br /> IX. COUNTYIDEPARTMENT USE ONLY <br /> Disapproved I Sanitary Permit Fee(Includes Groundwater Date esus Issuing Agent Signature(No Stamps) <br /> Fee) i <br /> Approved ❑ Suroharge Owner Given Initial I j\r� q-y� <br /> Adverse Determination l o5 V LJ <br /> X. CONDITIONS OF APPROVALIREASONS FOR DISAPPROVAL: <br /> SBD-6398(formerly Plb-67)(R.11/88) DISTRIBUTION: Original to County,One Copy To:Safety&Buildings Division,Owner,Plumber <br />