Laserfiche WebLink
HR SANITARY PERMIT APPLICATION COUNTY <br /> In accord with ILHR 83.05,Wis.Adm.Code YK�� I <br /> UM--aao�a3 <br /> ;TATE SANITARY PERMIT# <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than 67314 <br /> Stfi X 11 inches In size. <br /> Check If revision to previous applicatlo <br /> —See reverse side for Instructions for completing this applicatio�EPROPERTY <br /> STATE PLAN I.D.NUMBER <br /> I. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATN. - LJ <br /> PROPERTY OWNER / LOCATION <br /> fi0Yv� C Ci �� � '/4, S 1= � T35 , N. R ifs WPROPERTYOWNER'S MAILING ADDRESS BLOCK# <br /> O o � <br /> CITY,STATE r ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER <br /> LkUIo a' l cJ t S`fs 3 /s <br /> qTY NEARESTR D <br /> it. TYPE OF BUILDING: (Check one) ❑State Owned VILLAGE: L/ t C 0/1AXIM W, <br /> r Go <br /> ❑ Public ®1 or 2 Fam.Dwelling-#of bedrooms a N <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. TYPE OF PERMIT: (Check only one in line A. Check line B if applicable) <br /> Reair of an <br /> A) 1. ® New 2. El Replacement 3. El Replacement of 4. ❑ Existing SyReconnect(stem on 5 ❑ Existing System <br /> System System Tank Only 9 <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 <br /> Other <br /> 21 ® Mound 30 El Specify Type 41 ❑ Holding Tank <br /> 11 ❑ Seepage Bed 42 ❑ Pit Privy <br /> 12 El Seepage Trench 22 In-Ground <br /> ❑ 43 ❑ Vault Privy <br /> 13 ❑ Seepage Pit Pressure <br /> 14 ❑ System-In-Fill <br /> VI. ABSORPTION SYSTEM INFORMATION: <br /> 1.GALLONS PER DAY J2.ABSORP.AREA 3.ABSIDI AREA 4. LOADING RATE 5. PERC.RATE 6. SYSTEM ELEV. 7. FINAL ELEVATION GRADE <br /> REQUIRED(sq.ft.) PROPOSED(sq.ft.) (Gels/day/sq.ft.) (Min./inch) <br /> 3 08 �.SO �5..� 1, 7 13-3- 3) Gj/p.(07 Feet 98,9,;)-Feet <br /> VII. TANK CAPACITY Site Fiber- Exper. <br /> in al Ions Total #of Prefab. A <br /> INFORMATION New istin Gallons Tanks Manufacturer's Name oncret Con- Steel glass Plastic pp <br /> strutted <br /> Tanks Tanks <br /> Se tic Tankor Holdin Tank <br /> WtESer G <br /> Lift Pum Tank/Si hon Chamber <br /> VIII. RESPONSIBILITY STATEMENT C® vK <br /> 1,the undersigned,assume responsibility for installation of the onsite sewage system shown on the site <br /> plans. <br /> MP/MPRSW No.: Business Phone Number: <br /> Plumber's Name(Print), Plu bar's SignaWre: o mps) <br /> 2�5 r Y YvtQ Y 71 f <br /> Plumber's Address(Street,City.Stale,�D e): AJ -e� 4cr <br /> IX. COUNTYIDEPARTMEN USE ONLY Issuing gent Signature(No Stamps) <br /> Disapproved Sanitary Permit Fee(Includes Groundwater a e sau 7/ l <br /> Surcharge Fee) y �� <br /> Approved ❑ Owner Given Initial —1y 0,C0 1C_1J" 3 <br /> / ` A v rmi tin O�..1/ <br /> X. CONDITIONS OF APPROVAUREASONS 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 />