Laserfiche WebLink
SANITARY PERMIT APPLICATION <br /> ZDMLHR In accord with ILHR 83.05,Wis.Adm.Code COUNTY hu rRa --- <br /> STATE SANITARY PERMIT#I �5�q <br /> —Attach complete plans(to the county copy only)for the system,on paper not less than ❑ / 14x1 <br /> 8%x 11 inches in size. ch if revislo 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. <br /> PROPERTY OWNER PROPERTY LOCATION <br /> —C_ ✓ '!lcd7 ''/a, S N, R ( E(or W <br /> PROPERTY OWNER'S M�'.A,JIIL/IINNGnG ADDRE��SnSy��� v�T LOT# �1 BLOCK# f+ <br /> CITY,STATE IP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER <br /> GJ /4 F /yIA/ Hsiuccs� P AZ. - <br /> It. TYPE OF BUILDING: (Check one) CITY / NEAREST ROAD <br /> ❑ State Owned ❑ VILLAGE <br /> ❑ Public 1 or 2 Fam. Dwelling—#of bedrooms PAR L NWY BF UMB ) <br /> III. BUILDING USE: (If building type is public,check all that apply) <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. TYIPEOF PERMIT: (Check only one in line A. Check line B if applicable) <br /> I <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 LSeepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 El 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 12.ABSORP.AREA 13.ABSORP.AREA 14. LOADING RATE 15. PERC.RATE 16. SYSTEM ELEV. 7. FINAL GRADE <br /> REQUIRED(sq.ft.) PROPOSED( q.ft.) (Gals/day/sq.ft.) (Min./' ch) ELEVATION <br /> �»� t h <br /> t J / Feet l�©'� Feet <br /> VII. TANK CAPACITY Site <br /> in allons 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 /> Septic Tank or Holdina Tank <br /> Litt Pum Tank/Siphon Chamber — 7 1 1G •• <br /> IK <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): I Plu tur :( Sta MP/MPRSW No.: Business Phone Number: <br /> Plumber's Address(Street,City,State,Zip Code): ��!n ' r ` <br /> ? P�—C C <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> Disapproved Sanitary Permit Fee(Includes Groundwater Date IssuedIssuing gent Signature(No Stamps) <br /> msµ, Surcharge Fee) <br /> pproved ❑ owner Given initial `�Ll I nG 4 rt-r'� 5 �g <br /> I Adverse Determination kl bs 0 <br /> X. CONDITIONS OF APPROVALIREASONS FOR DISAPPROVAL: <br /> SBD-63e8(formerly Plb-67)(R.11/88) DISTRIBUTION: Original to County,One Copy To:Safety&Buildings Division,Owner,Plumber <br />