Laserfiche WebLink
SANITARY PERMIT APPLICATION COUNTY <br /> DILHR In accord with ILHR 83.05,Wis.Adm.Code <br /> tea_ <br /> STATES/ANITA PERMIT III <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than ( 151, )� <br /> 8'f,x 11 inches in size. ❑ Check If rsvisi n 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 0, ,-" -4µ, 4( PROPERTY LOCATION <br /> S AP4Cr6, , 4AJ %IL j% S d0 T yo N, R B (o W <br /> PROPERTY OWNER'S MAILING ADDRESS LOT# BLOCK# <br /> 3(':o 0 0. /1/ Rd 7 '1-8 1 I <br /> CITY,STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUM ER <br /> 3s'i a 3 to/z o2-�Q U a <br /> It. TYPE OF BUILDING: Check One CITY : NEAREST ROAD <br /> ( > State Owned o VILLAGE Prd s f of <br /> Public ❑ Dwellings of or 2 Fam. Dwellingof bedrooms— <br /> III. BUILDING USE: (If building type is public,check all that apply) ao-9/7S-ba-__)C0 <br /> as 9/�s-0a- <br /> 1 El ApVCondo <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 ET 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 Seepage Bed 21 ❑ Mound 30 ❑ SpecityType 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: a _QeaJj 4tL •hd A.7rr.. .fi!,Q< 9a Yo <br /> 1.GALLONS PER 72.ABSORP.AREA 3.ABSORP.AREA 4. LOADINGRATE 5. PERC.RATE 6. SYSTEMELEV. 7. FINALGRADE <br /> / REQUIRED(sq.ft.) PROPOSED(sq.ft.) (Gals/day/sq.ft.) (Min./inch) EVATION <br /> p? 7 U O /too�_ ra'/ cCp / <br /> 0 0 . I 9,.J,5,�0 feet 9 6 0 Feet <br /> VII. TANK CAPACITY Site <br /> in allons Total #of Manufacturer's Name Prefab. Con- Steel Fiber- Plastic Exper. <br /> INFORMATION New xistin Gallons Tanks Concrete glass Apo- <br /> Septic <br /> pp.Se tic Tank or Holdin Tanks Tanks Tank .. c.� strutted <br /> Lift Pum TanWSi hon Chamber rJ <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 Sig urs: Stem ) NP/MPRSW No.: Business Phone Number: <br /> 74— `�7n? •o?7�s <br /> Plumber's Aldress(Street,City,State,Zip Code): <br /> 66- k !! <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved Sani ry Permit Fee(Includes Groundwater DateIssued- Is s ng gent Signe (No Stamps) <br /> Approved <br /> El Given Initial I surcharge Fee) <br /> Adverse Det rmin i n l /LTO �V <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(formerly Plb-67)(R.11/86) DISTRIBUTION: Original to County,One Copy To:Safety&Buildings Division,Owner,Plumber <br />