Laserfiche WebLink
DILHR SANITARY PERMIT APPLICATION <br /> In accord with ILHR 83.05,Wis.Adm. Code COUNTY <br /> STATE,,,,ssssANIITIA(�RV`P` MIT#�`�'l!-"1C/ <br /> -Attach complete plans(to the county copy only)for the system,on paper not less than �'�1AR T J�17� <br /> 8%x 11 inches in size. ❑ c kifrevision 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 /> PROPERTYOWNER PROPERTY LOCATION <br /> _Z- v4v1So+-. 5E '/a NE ''/y, S Zto T 4�0, N, R 14 W <br /> PROPERTY OWN R'S MA/ILING ADDRESS LOT If ++ry1 LCT BLOCK# <br /> o• B.K Z(p(p W • '�Yl t <br /> CITY,STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER <br /> c I J' 15a,D 1 pP. <br /> L IIs <br /> 11. TYPE OF BUILDING: (Check one) ❑State Owned VILLAGE NEAREST ROAD <br /> ❑ Public ®1 or 2 Fam. Dwelling-#of bedrooms_L_ PAR ELTAXN' USM <br /> III. BUILDING USE: (If building type is public,check all that apply) ,.(� 14194a- oI 7Z!-) <br /> 1 ❑ Apt/Condo v1 <br /> 2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility <br /> 3 ❑ Campground 7 ElMerchandise: Sales/Repairs 11 ElRestaurant/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 /> 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 ❑ 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 DAY 2.ABSORP.AREA 3.ABSORP.AREA 4. LOADING RATE 5. PERC.RATE 6. SYSTEM ELEV. 7. FINAL GRADE <br /> REQUIRED(sq.ft.) PROPOSED(sq.ft.) (Gals/day/sq.ft.) (Min./inch) ELEVATION <br /> /$O R0$- //05 C',+SS / 95.Z Feet 9(0.7 Feet <br /> CAPACITY <br /> VII. TANK Site <br /> in allons Total #of Prefab. Fiber-INFORMATION New istin Gallons Tanks Manufactureis Name oncret Con- Steel glass PlasticjEjxper. <br /> Tanks I Tanks strutted <br /> Septic Tank or Holdin Tank O 7$0 / Kh r• XLj <br /> Litt Pump Tank/Siphon Chamber <br /> VIII. RESPONSIBILITY STATEMENT <br /> I,the undersigned,assume responsibility for installation of the onsitg sewage system shown on the attached plans. <br /> Plumber's Name(Print): Plumber's Signature:(No Sta ) MP/MPRSW No.: Business Phone Number: <br /> w 5 t•,Son ,Q,, - P33�j3 7/S b3S 7SgS <br /> Plu ber's Address(Stre ,City,State,Zip Code): <br /> D . Bx.-7Ioo/tev LU. 6 <br /> 4801 <br /> IX. COUNTY/DEPARTMENT US ONLY <br /> ❑ DisapprovedSanitary Permit Fee(Includes Groundwater Date ssue Iss Agent Signa r (No Stamps) <br /> Approved El Owner Given Initial Iryr I(M1 -) surcharge Fee) �-,1( <br /> Adverse termination I`-'-� ` `-"-' I <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 />