Laserfiche WebLink
DILHR SANITARY PERMIT APPLICATION <br /> In accord with ILHR 83.05,Wis.Adm.Code COUNTY <br /> �• Y� STATE SANITARY PERM # IV-55Z <br /> —Attach complete plans(to the county copy only)for the system,on paper not less than ( I ,t-7 S% ) <br /> 834 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 /> 1. APPLICANT INFORMATION—PLEASE PRINT ALL INFORMATION. <br /> PRQqERTY OWNER PROPERTY LOCATION <br /> / '/4 a, S T N, R E (OrKW.? <br /> P OPERTY OWNERS MAILING ADDRESS L`OT# BL-661F# <br /> &1%2 � r? sal ' . 4 <br /> CITYVST TE ZIP CODEPHONE NUMBER BDIVISION NAME OR CSM NUMBER <br /> II. TYPE OF BUILDING: (Check one) ROAD <br /> CIN NEAOREST <br /> ❑ State Owned VILLAGEQ /4V(y_, <br /> ❑ Public1 or 2 Fam. Dwelling-#of bedroomsPARCEL TAX NUMBEK(b) <br /> (�( <br /> III. BUILDING USE: (If building type is public,check all that apply) Q Z� Li�Z�—Q Lt"_ <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. 0Replacement 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 /> REQUI�RE/P/(sq.ft.) PROPOSED sq.ft.) (Gala/day/sq.ft.) (Min./inch) ELEVATION <br /> `Y i 1 .� 9 .IsFeet I Feet <br /> CAPACITY <br /> VII. TANK Site <br /> in allona Total #of Prefab. Fiber- Exper. <br /> INFORMATION New istin Gallons Tanks Manufacturer's Name oncret Con- Steel glass Plastic App <br /> Tanks Tanks strutted <br /> Se tic Tank or Holdina Tank <br /> Lift Pump Tank/Siphon Chamber <br /> VIII. RESPONSIBILITY STATEMENT <br /> 1,the undersigned,assume responsibility for Installation of the onsite sewage system shown on the attached plans. <br /> Plumber's Name(Print): Plumber's Signature:(No Stamps) MP/MPRSW No.: Business Phone Number: <br /> Plumber's Address(street,City,State,Zip ode): <br /> m ei u/ - 3 <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> Disapproved Sanitary Permit Fee(Include groundwater Date Issuedlea Agent Sig ure(No Stamps) <br /> Surcharge Fee) <br /> Approved ❑ Owner Given Initial <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: % <br /> SBD-M(formerly Plb-67)(R.11/88) DISTRIBUTION: Original to County,One Copy To:Safety&Buildings Division,Owner,Plumber <br />