Laserfiche WebLink
SANITARY PERMIT APPLICATION <br /> In accord with ILHR 83.05,Wis. Adm. Code COUNTY <br /> STA E SAN ITARY PERMIT# <br /> -Attach complete plans(to the county copy only)for the system, on paper not less than l � �-1-7 10' <br /> 81/2 x 11 inches In Size. Check 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. <br /> PROPERTY OWNER PROPERTY LOCATION q!1/o .L. <br /> .014 salw_Z. 5E '/4 n-3 %, S 34- T 40, N, R 14 ISM W <br /> PROPERTY OWNER'S MAILING ADDRESS LOT## BLOCK## <br /> C.? Foyc IZO -7— <br /> CITY,STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER <br /> o I G �3/8�� V, ),S P, 5 <br /> II. TYPE F BUILDING: (Check one) CITY NEAREST ROAD <br /> State Owned ❑ VILLAGE :f2l TOWN <br /> ❑ Public 5<1 or 2 Fam. Dwelling-##of bedrooms_27� PARCELTAXX NUMBER(S) <br /> III. BUILDING USE: (If building type is public,check all that apply) (+- 7", l { J�� -©i Eno <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. 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) p �E,LEEVATION <br /> 3e0 .9 21 � -3 2 7 93 �J Feet ZA6v Feet <br /> CAPACITY <br /> VII. TANK in allons Total ##of Prefab. Site Fiber Exper. <br /> INFORMATION New xistin Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App. <br /> Tanks Tanks structed <br /> Septic Tank /OOD <br /> Lift Pump Tan er 400 <br /> Vlll. RESPONSIBILITY STATEMENT <br /> I,the undersigned, responsibility for installation of the onsite sewage system shown on the attached plans. <br /> Plumber's IQQ®��1nt ev/�a�p�1®p� Plumber's Signat :(No Stamps) WP/MPRSW No.: Business Phone Number: <br /> NCR 59, Box 478d IV 3393 <br /> Plumber's A31ftgereefflly,SMOT Code): <br /> (7151635-7482 <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑ Disapproved Sanitary Permit Fee(Includes Groundwater ate IssuedIssuin ent Signature(No Stamps) <br /> A roved I Surcharge Fee) <br /> pp ❑ Owner Given Initial % <br /> Adverse Determination \ ✓ � �`X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(R.08/93) DISTRIBUTION: Original to County,One Copy To:Safety&Buildings Division,Owner,Plumber <br />