Laserfiche WebLink
��ILHR SANITARY PERMIT APPLICATION <br /> In accord with ILHR 83.05,Wis.Adm.Code couNTv <br /> summmommommoomms <br /> :u �l�C <br /> ���•�� RY <br /> STATE NITARMIT#'� <br /> -Attach conn l@te plans(to the county copy only)for the system,on paper not less than ITA <br /> 8'%x 11 inches in size. ❑ Shack if revl 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. S IQ — ez <br /> PROARTY OWNER PROPERTY LOCATION <br /> '/4�5' '/4,S`3 T , N, R (� E (or <br /> PROPERTY OWNER'S MAILING ADDRESS LOT# BLOCK# <br /> �z <br /> CITU, TATE ZIP C DE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER <br /> 11. TYPE OF BUILDING: (Check one CITY NE EST ROAD <br /> ❑ State Owned ITY <br /> ❑ Public Of or 2 Fam.Dwelling-#of bedroom PAIFIGEL TAX Nu <br /> III. BUILDING USE: (If building type is public,check all that apply) �_ L� �(��� <br /> 1 El ApUCondo <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 PER <br /> (Check only one in line A. Check line B if applicable) <br /> A) 1. l�� 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 Oth,,,eeee,,,r((( <br /> 11 El Seepage Bed 21 ❑ Mound 30 El SpecifyType 41 {A1 Holding Tank <br /> 12 EJ 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 13.ABSORP.AREA 14. LOADING RATE 1.5. PERC.RATE 6. SYSTEM ELEV. 7. FINAL GRADE <br /> 1_5� REQUIRED(sq.ft.) PROPOSED(sq.ft.) (Gals/day/sq.ft.) I (Min./inch) ELEVATION <br /> Feet Feet <br /> VII. TANK CAPACITY Site <br /> in gal Ions Total of Prefab. jFiber- <br /> r.INFORMATION New istin Gallons Tanks Manufacturer's Name onct Con- SteePlastic App <br /> Tanks Tanks strutted <br /> Septic Tank or Holding Tank — <br /> Lift Pump Tank/Siphon ChamberI El <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' o S mps MP/MPRSW No.: Business Phone Number: <br /> Plum er's Address(Peet,City, tate,Zip Code): <br /> 77 <br /> IX.litCOUNTYIDEPARTMENT USE ONLY <br /> ❑ Disapproved Sanitary Permit Fee(Includes Groundwater Dateissued <br /> Issuing Ag t S' netur (No S s) <br /> Approved ❑ Owner Given Initial surcharge Fee) <br /> Adve D rmin I n loE;' do5-,)A-q <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(formerly Plb-67)(R.11/88) DISTRIBUTION: Original to County,One Copy To:Safety&Buildings Division,Owner,Plumber <br />