Laserfiche WebLink
7D—IL-HR <br /> SANITARY PERMIT APPLICATION <br /> In accord with ILHR 83.05,Wis.Adm.Code COUNTY 1 <br /> tYl4rl <br /> Emma STATE ANITARY MIT#) <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than P 53L1 <br /> 8'%x11inches insize. ❑ check If revisligAo 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 PROP RTY LOCATION <br /> 5 • C(e P/ N It'/4A;W 1/4, Scp_�'V T Q N, R /. W <br /> PROPERTY OWNER'S MAILING ADDRESa LOT# BLOCK# <br /> ,9 Leg KA <br /> CITY,STATEI ZIP CODE PHONE NUMBER SUBDIVINON NAME OR CSM NUMBER q U, LlT� <br /> w 5 GS & <br /> 11. TYPE O UILDING: (Check one) CIN NEAREST ROAD <br /> 1f�� ❑ Stat@OWned VILLAGE L; 2C F ZK �d <br /> ❑ Public N 1 or 2 Fam.Dwelling,#of bedrooms` A L Umb R( 1) <br /> III. BUILDING USE: (If building type is public,check all that apply) a- 4 as 4 -0 3- S/D <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. TY(PPEr OF PERMIT: (Check only one in line A. Check line B if applicable) <br /> A) 1. I,�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 Other <br /> 11 Seepage Bed 21 ❑ Mound 30 ❑ Specify 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 PER 1 2.ABSORP.AREA 13.ABSORP.AREA 14. LOADING RATE 5. PERC.RATE 6. SYSTEM ELEV. 7. FINAL GRADE <br /> REQUIRED(sq.ft.) PROPOSED(sq.ft.) (Gals/day/sq.ft.) -3--3'- <br /> C� c^' pELEVATION <br /> 3e c% 10 ;?_0 1 7 3"3 /�, Feet Feet <br /> VII. TANK CAPACITY Site <br /> in allons Total #of Prefab. Fiber- Exper. <br /> INFORMATION New istin Gallons Tanks Manufacturer's Name oncret Con- Steel glass Plastic App <br /> Tans Tanks strutted <br /> tic Q orHoldino Tank <br /> Lift Pump Tank/Siphon Chamber <br /> VIII. RESPONSIBILITY STATEMENT <br /> I,the undersigned,assume responsibility for i tallation of the onsite sewage system shown on the attached plans. <br /> Plumber's Name(Print): Plumb 's Signature:(Nota ) MP/MPRSW No.: Business Phone Number: <br /> Plumber's Address(Street pi ,State, ip Code): <br /> X. UNTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved Sanitary Permit Fee(Includes Groundwater Date IssuedIssu' g A nt Signet o Stamps) <br /> (((��� Surcharge Fee) ^ <br /> Approved ❑ Owner Given initial '�� Oo <br /> Adverse Determination <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(formerly Plb87)(R.11/88) DISTRIBUTION: Original to County,One Copy To:Safety&Buildings Division,Owner,Plumber <br />