Laserfiche WebLink
�.DILHR SANITARY PERMIT APPLICATION COUNTY <br /> In accord with ILHR 83.05,Wis.Adm.Code u I E <br /> ommoms <br /> STATE SANITARY P�RMIT#aOIQS(t <br /> –Attach complete plans(to the county copy only)for the system,on paper not less than (j 7 arc/ ) u` <br /> 8%x 11 inches in size. ❑ Check if revittice to previous 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 /> PROPERTY OWNER P OPERTY LOCATION <br /> LA �i�Rt4c NoTom E '%944 %, S JZ T N, R 'l E (o W <br /> PROPERTY OWNER'S MAILING ADDRESS LOT# bLOCK# <br /> S <br /> CITY,STATE ZIP CODE PHONE NUMBER 86101911i'18084160 ME OR OS144441:111ill'515A <br /> M oce3 7q� 150 <br /> 11. TYPE OF WILDING: (Check one) CIN NE REST ROAD <br /> State Owned VILLAGE �) � � <br /> ❑ #of P rW E C RO <br /> Public $a1 or 2 Fam. Dwellingbedrooms <br /> 111. BUILDING USE: (If building 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 ❑ 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. ❑ 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 q�l Seepage Bed 21 ❑ Mound 30 EJSpecify 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 PERTI 2.ABSORP.AREA 3.ABSORP.AREA 4. LOADING RATE 5. PERC.RATE 6. SYSTEM ELEV. 7. FINAL GRADE <br /> REQUIRED(sq.ft.) PROPOSED(sq.ft.) (Gals/day/sq.tt.) (Min./inch) ELEVATION <br /> r <br /> `iE0 120 cis .1 Feet ,Z Feet <br /> CAPACITY <br /> VII. TANK in gall ns Total #of Prefab. Site Fiber- Exper. <br /> INFORMATION New is6n Gallons Tanks Manufacturer's Name oncrete Con- Steel glass Plastic App <br /> Tanks Tanks structed <br /> Septic Tank or Holdino Tank <br /> Lia Pum Tank/Si hon 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 mps) MP/MPRSW No.: Business Phone Number: <br /> Ips ( �rs 0 ts7 <br /> P umber's Address(Street,City,State,Zip Code): <br /> IX. OUNTY/DEPARTMENT USE ONLY <br /> Ej Disapproved Sanitary Permit Fee(Includes Grounowater Date Issued Issuln nt Sig t e(No Stamps) <br /> Approved ❑ Owner Given Initial surcharge Fee) <br /> Adverse Determination <br /> / <br /> X. 0NDITI NNS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(formerly Plb-67)(R.11/83) DISTRIBUTION: Original to County,One Copy To:Safety 6 Buildings Division,Owner,Plumber <br />