Laserfiche WebLink
SANITARY PERMIT APPLICATION COUN <br /> I�YTYr <br /> DILHR In accord with ILHR 83.05,Wis. Adm.Code <br /> �~�• �� STATES IRY RMIT#l�fzin3 <br /> —Attach complete plans(to the county copy only)for the system,on paper not less than / b <br /> ❑8'%x 11 inches in size. Chif eevvlssio o 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 j,Jo <br /> PROPERTY OWNER PROPERTY LOCATION <br /> j z At '/4 ''/4, S 6 T O , N, R re <br /> PROPERTY OWNER'S MAILING ADDRESS LOT# BLOCK# <br /> 431-Q NA <br /> CITY,STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER <br /> It. TYPE OF BUILDING: (Check one) CITY NEAREST ROA <br /> / ❑State Owned LAGE ?JAGkJoN �A (i�( <br /> ❑ Public Lr��J 1 or 2 Fam. Dwelling-#of bedrooms— VILAR EL AX UMBER( ) <br /> Ill. BUILDING USE: (If building type is public,check all that apply) 1�—L� r)q`-7IX�1TJV7/11 <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 ❑ 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 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 /> y� REQUIRED(sq.ft.) PROPOSED(sq.ft.) (Gels/day/sq.ft.) (Min./inch) / ELEVATION <br /> Vv O i 9't7. / Feet 4?7,_3 Feet <br /> VII. TANK CAPACITY Site <br /> in allons Total #of Prefab. Fiber- Exper. <br /> INFORMATION New istin Gallons Tanks Manufacturer's Name oncrete Con- Steel glass Plastic App <br /> Tanks Tanks strutted <br /> Septic Tank or Holdin Tank O A� <br /> Lift Pum Tank/Si hon Chamber <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 S' inatur '(No Sta s) ,PIPIMPRSW No.: Business Phone Number: <br /> C&C JCq,4,Vr4 <br /> Plumber's Address(Street,City,State,Zip Code): <br /> lel. <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> Disapproved Sanitary Permit Fee(Includes Groundwater e e ssue Issuing A ent Signature(No Stamps) <br /> ASurcharge Fee)pproved ❑ Owner Given Initial yy 105 C <br /> Adverse Determination ,f IV, Ulm. fV <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(formerly Plb-67)(R.111/88) DISTRIBUTION: Original to County,One Copy To:Safety&Buildings Division,Owner,Plumber <br />