Laserfiche WebLink
SANITARY PERMIT APPLICATION COUNTY <br /> EDILHR In accord with ILHR 83.05,Wis.Adm.Code <br /> STATE SSSAAANITARY fR�ERMIT#'GI �r7o <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than / r � p0 <br /> 8'%x 11 inches in size. ❑ C k7 to previous application <br /> -See reverse side for Instructions for Completing this application. STATE PLAN I.D.NUMBER <br /> 1. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION. <br /> PROPERTY OWNER p PRORF$TY LOCATION <br /> '/4�'" '/4,S 32- T 0, N, R (p E (or W <br /> PROPERTY OWNER'S MAILING ADDReSS LOT#� BLOCK# <br /> 3 IJ <br /> CITY,STATE ZIP CODE I PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER <br /> JEFF IEs 3 <br /> 11. TYPE OF BUILDING: (Check one) El State Owned CITY © �- 1� NEARfr3sT�j_Q(j� <br /> ❑ Public X 1 or 2 Fam. Dwelling-#of bedrooms 2 A uM 1� W�j �J <br /> III. 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. NPEOFPERMIT: (Check only one in line A. Check line B if applicable)A) New 2. ❑ Replacement 3. ❑ Replacement of 4. El 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 ❑ Speciy 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 PER77 2.ABSORP.AREA 13.ABSORP.AREA 14. LOADING RATE 15. PERC.RATE 16. SYSTEM ELEV. 17. FINAL GRADE <br /> REQUIRED(sq.ft.) PROPOSED(sq.ft.) (Gals/day/sq.ft.) (Min./inch) /� QQ ELEVATION <br /> 3 oO O Q 2 3 R 2. Z Feet "1 Feet <br /> VII. TANK CAPACITY I 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 /> Septic Tank or Holding Tank <br /> Lift Pump Tank/Siphon 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): PI bar's Signature:(No S mps) MP/MPRSWNo.: Business Phone Number: <br /> Ir-HARD HOP045 �I2tb IS g�b,�(S7 <br /> Plumber's Address(Street,City,State,Zip Go--,. <br /> 7- 17&0 14wWU.STOZ , I . S 8 3 <br /> IX. COUNTY/DEPARTMENT SE ONLY <br /> ❑ Disapproved Sani ry Permit Fee(includes Groundwater ae ssue Issuingent Signature(No Stamps) <br /> Approved ElOwner Given Initial Surcharge Feel /�- <br /> Adverse Determination '3,a00 2 wLa� <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-8398(formerly Plb-67)(R.11/88) DISTRIBUTION: Original to County,One Copy To:Safety 8 Buildings Division,Owner,Plumber <br />