Laserfiche WebLink
SANITARY PERMIT APPLICATION COUNTY <br /> In accord with ILHR 83.05,Wis.Adm.Code U�� <br /> STA E SANITARY PERMIT <br /> —Attach complete plans(to the county copy only)for the system,on paper not less than ) ] /O <br /> �� <br /> 8'hxllinches insize. ❑ heck iirevi� s' ntopreviousapplication <br /> —See reverse side for instructions for completing this application. STA E PLAN I.D.NUMBER <br /> I. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION. <br /> PROPERTY OWNER PROPERTY LOCATION 'r <br /> ( CHAPeP /4 '/4, S Z T 0 , N, q E(or OW <br /> PROPERTY OWNER'S MAILING ADDRESS LO # BLOC # <br /> Z59 056 D- V'�. 5 <br /> CITY,STATE I ZIP CODEH NE NUMBER SUBDIVISION NAME OR CSM NUMBER <br /> Spoo W 1. So I P�I5 35-SRO <br /> LJ ST ROAD <br /> It. TYPE OF BUILDING: (Check one) El State Owned VILLAGE; NE 3`l5K M <br /> CO <br /> El Public ®1 or 2 Fam. Dwelling–#of bedrooms 9= R E <br /> PAL AX NUMBER( ) <br /> III. BUILDING USE: (If building type is public,check all that apply) 4— O� <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. TYPE OF PERMIT: (Check only one in line A. Check line B if applicable) <br /> A) 1. ❑ New 2. X 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 /> 11Seepage Bed 21 ElMound 30 ❑ Specify Type 41 ElHolding 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 PER71 2.ABSORP.AREA 13.ABSORP.AREA 14. LOADING RATE 5. PERC. RATE 16. SYSTEM ELEV. 7. FINAL GRADE <br /> REQUIRED(sq.ft.) PROPOSED(sq.ft.) (Gals/day/sq.ft.) (Min./inch) gE/LEVATION <br /> 3oa 5 3 1 3 $ Feet !(O 3 Feet <br /> VII. TANK I <br /> CAPACITY Site <br /> in allons Total #ot Prefab. Fiber- Exper. <br /> INFORMATION New istin Gallons Tanks Manufacturer's Name oncrete Con- Steel glass Plastic App <br /> Tanks Tanks strutted <br /> Septic Tank or Holdin Tank �'�ll-P <br /> Lift Pum Tank/Siphon Chamber 6 <br /> VIII. RESPONSIBILITY STATEMENT <br /> I,the undersigned,assume responsibility for installation of the onsite sewage system shown on the attached p lans. <br /> Plumber's Name(Print): Plumber's Signature:(No Stamps) MP/MPRSW No.: Business Phone Number: <br /> f d H A Rv D yxlN s t� LLR,,( 3 42L l5 866 I577 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 7 <br /> 2-7766 <br /> 76 b9 W 4 2;5 oB57rg W 1 <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved Sanitary Permit Fee(Includes Groundwater a e Issued Ise n Ag nt Sign a IN Stamps) <br /> Surcharge Fee) <br /> Approved ❑ Owner Given Initial -1 1� OCq <br /> Adverse Determination / <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(R.08/93) DISTRIBUTION: Original to County,One Copy To:Safety 8 Buildings Division,Ow net,Plumber <br />