DCPZP-1992-01206 - Laserfiche WebLink

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iILiiR SANITARY PERMIT APPLICATION COUNTY In accord with ILHR 83.05,Wis.Adm.Code PA/■■ C1 cia-009r7 STATE SANITARY PERMIT# —Attach complete plans(to the county copy only)for the system,on paper not less than j 732 Cj 8%x 11 inches in size. ❑ Check if revision to previous application -See reverse side for instructions for completing this application. STATE PLAN I.D.NUMBER I. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION. /3 9 0037 PROPERTY OWNER ,�- PROPERTY LOCATION /01& ry(X ' S' 44 ' %,S5 Te , N, R (or)W PROPERTY OWNER'S MAILING ADDRESS LOT# 7 BLOCK## 6/9 C W T r' CITY,STATE ZIP C091#.. - PHONE NUMBER SUBDIVISION NAME OR CRS f 1UMBER 64A'-K L-�A17? _c3 5 ( 6af )7a 28x2.: 6-a 6 3 II. TYPE OF BUIL IN : (Check one) ID CITY NEAREST ROAD ' ❑State Owned LAGE: ,�G� r,,(4 / I C%/i xf QQWy OF� ❑ Public 7 1 or 2 Fam.Dwelling-#of bedrooms �ELTAXNUMBER(S) bc d, v, -I\ III. BUILDING USE: (If building type is public,check all that apply) • ( N e o B O (, -3 4.4 - 9 S oo / v 4 III 1 ❑ AptCondo 2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility 3 ❑ Campground 7 ❑ Merchandise: Sales/Repairs 11 ❑ Restaurant/Bar/Dining 4 ❑ Church/School 8 ❑ Mobile Home Park 12 ❑ Service Station/Car Wash 5 ❑ Hotel/Motel 9 ❑ Office/Factory 13 ❑ Other: Specify IV. TYPE F PERMIT: (Check only one in line A. Check line B if applicable) A) New 2. ❑Replacement 3. ❑ Replacement of 4. ❑ Reconnecting-MI6 Repair of an System System Tank Only Existing Sys Existing System B) ❑ A Sanitary Permit was previously issued. Permit# — Date I d Mt 1 1 111L V. TYPE OF SYSTEM: (Check only one) Non-Pressurized Distribution Pressurized Distribution Experimental bane Coun4y Envirb} �r.t! 11 • -eepage Bed 21 111 Mound 30 ❑ Specify Type ail �'oarf'A ❑ Holding Tank 1 ►1 Seepage Trench 22 ❑ In-Ground 42 ❑ Pit Privy 13 • Seepage Pit Pressure 43 ❑ Vault Privy 14 ❑ System-In-Fill VI. ABSORPTION SYSTEM INFORMATION: 1.GALLONS PER DAY 2.ABSORP.AREA 3.ABSORP.AREA 4. LOADING RATE 5. PERC.RATE 6. SYSTEM ELEV. 7. FINAL GRADE REQUIRED(sq.ft.) PROPOSED(sq.ft.) (Gals/day/sq.ft.) (Min./inch) ipg, 2.. ELEVATION q.CD 70 7 .6 atxd We —3 Feet may.f Feet VII. TANK CAPACITY Site in gallons Total ##of Prefab. Fiber- Exper. Con- INFORMATION New Existing Gallons Tanks Manufacturer's Name Concrete structed Steel glass Plastic App. Tanks Tanks , S 'N eptic Tank or Holdine-Tank (OD .44" w t)v ( 0'' l/ El a El El El Lift Pump Tank/Sipfivm6l+smber /f13 -4 a VIII. RESPONSIBILITY STATEMENT I,the undersigned,assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber's Name(Print): PIu97ber's Signature:(No Stamps) l MP/MPRS No.: Business Phone Number: E z,t) // 67E)2-z0 `� I 3 3 ( 41,? )75J-02i7/ Plumber's Address(Street,City,State,Zip Code): ~IX. COUNTY/DEPARTMENT USE ONLY Issui Agent Signature(No Stamps) ❑ Disapproved Sanitary Permit Fee(Includes Groundwater a e ssue 9 g ^ p ) Surcharge Fee) ��_1� �� ,Approved ❑ Owner Given Initial �' 1'-/15 Op ' i r,z'n;;: L'.6,-6-k7-.6 rc� t4'_4 V Adverse Determination X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: p^-4_4_,-,---.0-,-1 , 4.- -,.•, `�-,-c ...f.....,; ,fit C' ° , GZ_ ic. -- mo , . VV 'SBD-6398(formerly PIb-67)(R.11/88) DISTRIBUTION: Original to County,One Copy To:Safety&Buildings Division,Owner,Plumber