Laserfiche WebLink
SANITARY PERMIT APPLICATION C >� <br /> In accord with ILHR 83.05,Wis.Adm. Code C e. <br /> r. e <br /> STA TSANIT Y PER IIT# <br /> —Attach complete plans(to the county copy only)for the system,on paper not less than ❑ � h`I4 <br /> 8%x 11 Inches In size. ack if revision 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. `IS- 31 -3 7 3 <br /> PROPERTY OWNERf/ PROPERTY LOCATION <br /> rice � ibLS N E '/s , S T3 , N, R <br /> PROPERTY OWNER'S MAILING ADDRESS LOT# BLOC # <br /> j r Sfi E. <br /> CITY,STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER <br /> 2�P S q39I -7 rS 06$36 <br /> It. TYPE OF BUILDING: (Check one) CITY NEA EST ROAD <br /> ❑State owned O VILLAGE:WIN OFk4 <br /> El Public Vr1 or 2 Fam. Dwelling--# bedroom PARCEL TAX NUMBERO <br /> III. BUILDING USE: (If building type is public,check all that apply) <br /> 1 ❑ ApVCondo <br /> 2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ outdoor Recreational Facility <br /> 3 ❑ Campground 7 ❑ Merchandise: Sales/Repairs 11 ❑ Re taurant/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. KNew 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 El Holding Tank <br /> 12 El 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 PEW7 2.ABSORP.AREA 3.ABSORP.AREA 4. LOADING RATE 5. PERC.RATE 6. SYSTEM ELEV. 7. FINAL GRADE <br /> L[ REQUIRED(sq.ft.) PROP—OfSE``D(sq.ft.) (Gals/day/sq.ft.) (Min./inch) ELEVATION <br /> r '� 3-7 S 3 ( 4� , Z.., '�� 00. Feet 102-111 <br /> VII. TANK CAPACITY Site <br /> in allons Total #of Prefab. Fiber- Exper. <br /> INFORMATION New istin Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App <br /> Tanks Tanks strutted <br /> e or Holdino Tank V 11600 C&jcimiq lyl <br /> ft Pum nk/Si hon Chamber <br /> VIII. RESPONSIBILITY STATEMENT <br /> I,the undersigned,assume responsibility for ins Ilation of the onsite sewage system shown on the attached r lans. <br /> Plumber's Name(Print): , Plumber s Signa re:(No MP/MPRSW No.: Business Phone Number: <br /> LS tey lam ) P .S? /S' 366-SkY <br /> Plumb Addre,5s(Street,City,State,Zip Code): P- �� <br /> ) tl <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved Sanitary Permit Fee(Includes Groundwater aessue IssuingA tSign r (NoStamps) <br /> A surcharge Fee) <br /> P�Approved ❑ Owner Given Initial c�9w l p <br /> Adverse Determination Y� <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBI}6398(R.08/93) DISTRIBUTION: Original to County,One Copy To:Safety&Buildings Division,Ow er,Plumber <br />