Laserfiche WebLink
0,Y) 16alp, <br /> ,ff 1k Safety and Buildings Division <br /> �. ; SANITARY PERMIT APPLICATION Bureau of Building Water Systems <br /> 201 E Washington Ave. <br /> In accord with ILH R 83 05,W is.Adm.Code P.O.Box 7969 <br /> Madison,WI 53707-7969 <br /> • Attach complete plans(to the county copy only)for the system,on paper not less County <br /> than 8 12 x 11 inches in size. <br /> • See reverse side for instructions for completing this application State Sanitary Permit Number <br /> CI9olt71 , <br /> The information you provide may be used by other government agency programs ❑Check it re inion to previous application <br /> [Privacy Law,s. 1 5.04(1)(m)I- Staf,�Plan I. .Number <br /> ON J <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATI <br /> Propert,y Owner Name P oper ty Location <br /> JTEtIE SE1.Jl5LL 1/4 E 1/4,S 2-!57T 361 , N, R 11' E(or)� <br /> Property Owner's Mailing Address Lot Number Block Number <br /> -P-0. BOX Z2 <br /> City,State Zip Code Phone Number r <br /> Gil EIP 5L- (lo136 ( C/(ES <br /> II. TYPE F BUILDING: (check one) ❑ State Owned ❑ Cit Nearest Road <br /> Public 1 or 2 FamilyDwelling- No. of bedrooms 3 Vowo of u5K IU RV- <br /> III. BUILDING USE: (if buildingtypelspubhc,checkallthatapply) Parcel TaxNumber(s) <br /> 1 ❑ Apartment/Condo nc) I S <br /> 2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility <br /> 3 ❑ Campground 7 ❑ Merchandise: Sales/Repairs 11 ❑ Resta rant/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 box on line A. Check box online B, if applicable) <br /> A) 1 ❑ New 2. ttReplacement 3. ❑ Replacementof 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 Number 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 Pressure 42❑Pit Privy <br /> 13❑Seepage Pit 43❑Vault Privy <br /> 14❑System-In-Fill <br /> VI. ABSORPTION SYSTEM INFORMATION: <br /> 1_ Gallons Per Day 2. Absorp.Area3. Absorp.Area 4. Loading Rate 5. Perc. Rate 6 System Elev. 7. Final Grade <br /> Req [red (sq. ft.) Proposed(s ft.) (Gals/day/sq. ft.) (Min./inch) 0-3 dd E7levation <br /> 3 , �j4j6 1. 7- .,�"7 Feet 10SS1 Feet <br /> Ca acit <br /> VII. TANK ingal Ions Total At of Tanks Concrete Ste Steel ger Plastic Aper <br /> INFORMATION Manufacturer's Name c n- <br /> New Existin str cted <br /> Tanks Tanks <br /> Septic Tank or Holding Tank 000 ❑ ❑ ❑ ❑ <br /> trft Pump Tank/Siphon Chamber Oil ❑ ❑ ❑ ❑ <br /> VIII. RESPONSIBILITY STATEMENT <br /> I,the undersigned,assume responsibility for installation of the onsite sewage system shown n the attached plans. <br /> Plumber's Name: (Print) Plumber's Si nat r Po, <br /> MP/MPRSW No.: Business Phone Number: <br /> c n/ 3�f26 (S S66- 8157 <br /> Plumber's Address(Street,City,Stale,Zip Code). <br /> yr 35- [A/605769WI, Stf 893 <br /> IX. COUNTY/ DEPARTMENT USE ONLY <br /> E]Disapproved Sanitary Permit Fee (includes Grounawawr ate ssue Issul ig e tSg t r (N amps) <br /> Approved �narge Fee) <br /> pp ❑Owner Given Initial r <br /> Adverse Determi t hT-�o <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> Snnb398(it.(15n)4) Dt"RIRUTION Originaltn Cnunty,Onecopy To.Safety BPuil,lingsnivtion,Owner,Ptum <br />