Laserfiche WebLink
` //'�"� ("�(1�v <br /> l )�" Safety and Buildings Division <br /> `�.SCOr15%11 SANITARY PERMIT APPLICATION 201 W.Washington Avenue <br /> In accord with ILHR 83.05,Wis.Adm.Code P O Box 7302 <br /> Department of Commerce Madison,WI 53707-7302 <br /> • Attach complete plans(to the county copy only)for the system,on paper not less County I/ <br /> than 81/2 x 11 inches in size. a `107 <br /> • See reverse side for instructions for completing this application St to Sanitary Permit Number �1 <br /> Personal information you provide may be used for seconds ��� ^� <br /> y p y secondary purposes ❑Check it revision to previous application <br /> (Privacy Law,s. 15.04(1)(m)]. �\ <br /> State Plan I.D.Number <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INF RMATI N <br /> PropertOwner Name roperty Location <br /> 1/4� v4,S Q- T A-1 ,N, R S E(one <br /> Prope wner's Mailin Address Lot Number Block Number <br /> o-f* v. 13 - 14 <br /> Ci y,State Zi Code Ph ne Number Subdi ision Name or CSM Number <br /> W1 ( s -51tr o . LtQ(-J ,ACRES <br /> 11. TYPE OF B I : (check one) ❑ State Owned ❑ Cit� Nearest Road <br /> Public 1 or 2 Family Dwellin -No.of bedrooms [3 VilTown OF 51,.J1 S <br /> 111. BUILDIN 11 : (if building type is public,check all that apply) Parcel TaxNumber(s) <br /> 1 ❑ Apartment/Condo 3Z I Oe 5bO <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 box on line A. Check box on line B,if applicable) <br /> A) 1. New 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an <br /> _____Syfstem ___ _System __ __ _____ Tank Only _ ____ _ Existing System __ __ Existing <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;1Seepage 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.Area 3. Absorp.Area 4. Loading Rate 5. Perc. Rate 6. System Elev. 7. Final Grade <br /> Required(sq.ft.) Proposed(sq.ft.) (Gals/da A ft.) (Min./inch) !�1 Elevation <br /> Feet q 6, Feet <br /> VII. TANK Capacity <br /> INFORMATION in gallons G101110 <br /> Tanks Manufacturer's Name cont ete con steel g ass Plastic Aper_ <br /> New Existin strutted <br /> Tanks Tank ^�, <br /> Septic Tank or Holding Tank Soo J IRP 11 0 M <br /> Lift Pump Tank/Siphon Chamber [IT ❑ ❑ ❑ <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) Plumber's Signature:(No Sta s) MP/MPRSW No.: Business Phone Number: <br /> I ` eC (0' Sr <br /> umbers Address(Street,City, ate,Zip Code): <br /> .0 bo y �J, esr�a W)- S403 <br /> IX. COUNTY/DEPART NT USE ONLY <br /> ❑Disapproved Sanitary Permit Feel(includes Groundwater ate issued Issuing e t Signa ure(N St ps) <br /> _60A roved Surcharge Fee) ` <br /> pp ❑OwnerGivenInitial <br /> Adverse Determination 6 <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(R.11/97) DISTRIBUTION: Original to County.One copy To: Safety&Buildings Division,Owner,Plumber <br />