Laserfiche WebLink
f- tA) �� 'npl <br /> Safety d Buildings Division <br /> Bureau of Building Water Systems <br /> SANITARY PERMIT APPLICATION 201 E.Washington Ave. <br /> 969 <br /> In accord with ILHR 83.05,Wis.Adm.Code P.O.Box <br /> Madison,,Wl WI 53707-7969 <br /> • Attach complete plans(to the county copy only)for the system,on paper not less Count Tom/ 771- JD� <br /> than 8112 x 11 inches in size. State Sanitary Permit Number / <br /> • See reverse side for instructions for completing this application 59 t / —7 <br /> The information you provide may be used by other government agency programs ❑ <br /> Chec revision to previous application. �— <br /> State Plan I.D.NWer <br /> [Privacy Law,s. 15.04(1)(m)]. <br /> I. APPLICATION INFORM TION - PLEASE PRINT ALL INFORMA peONrty ocation c`,' /�' <br /> Pro rtyownerName /t)U4 Ali,) 1/4,S o7eZ T 3Y ,N, R `gE(Or) <br /> PZ"'i'tj s C Lot Number Block Number <br /> Property Owner's Mailing Address p / '�- <br /> 3 i <br /> �y S fs / Zip Code Phone Number a73 Subdivision arn�or urylber a,5- <br /> b u r f� sY8 5�� ( ) 9 V <br /> � Ity a <br /> Nearest Road <br /> II. TYPE OF BU DING: (check one) ❑ State Owned Village p <br /> Public 1 or 2 Famil Dwellin -No.of bedrooms town of 4 y�er^ ©` <br /> Parcel Tax Number(s) <br /> III. BUILDINGUSE: (If building type is public,check all that apply) 9/0 <br /> C) � �5-aa <br /> 1 ❑ Apartment/Condo 10 E] Outdoor Recreational Facility <br /> 2 ❑ Assembly Hall 6 ❑ Medical Facility/NursingHome 11Restaurant/Bar/Dining <br /> 3 E] Campground 7 F1 Merchandise: Sales/Repairs 12 E] Service Station/Car Wash <br /> 4 ❑ Church/School 8 ❑ Mobile Home Park <br /> 5 ❑ Hotel/Motel <br /> g ❑ office/Factory 13 E] Other: specify <br /> IV. TYPE OF PERMIT: (Check only one box on line A. Check box online B,if applicable) <br /> )nection of 5. ❑ Repair of an <br /> New 2. V Replacement 3. ❑ Replacement of 4- ❑ Reco _S stem _ Existing <br /> A) 1. ❑ �` stem Tank Only _ _Existing -y_- ---------g - <br /> ------System --------System -------------------- -------------- <br /> B) ❑ A Sanitary Permit was previously issued. Permit Number <br /> Date Issued <br /> V. TYPE OF SYSTEM: (Check only one) Other <br /> Pressurized Distribution Experimental <br /> Non Pressurized Distribution HoldingTank <br /> 11 []Seepage Bed 21 Mound 30❑Specify Type 41 ❑ <br /> 42❑Pit Privy <br /> 12❑Seepage Trench 22❑In-Ground Pressure 43❑Vault Privy <br /> 13❑Seepage Pit <br /> 14❑System-In-Fill <br /> VI. ABSORPTION SYSTEM INFORMATION: 7. <br /> 1. Gallons Per Day 2. Absorp.Area 3. Absorp.Area 4. Loading Rate 5. Perc. Rate 6. System Elev. Elevation <br /> onrade <br /> Required (sg ft.) Pro ft) Ga day/sq-ft.) (MM`/inch) q��s—Feet e�Feet <br /> VII TANK Capa�elty Total #Of Prefab. Site Fiber- plastic Exper. <br /> in gallons Manufacturer's Name Concrete Con- steel glass App. <br /> INFORMATION New Existin Gallons Tanks strutted <br /> Tanks Tanks ) ❑ ❑ ❑ D ❑ <br /> Septic Tank or Holding Tank �1po d a ❑ ❑ ❑ ❑ ❑ <br /> t lft Pump Tank/Siphon Chamber O) a,?)) <br /> VI11. RESPONSIBILITY STATEMENT <br /> I,the undersigned,assume responsibility for installation of the onsite sewage system shown on Uh eas attached <br /> Number: <br /> plans./ Plumber'sSignatur :(NoStamps) MP/MPRSW/No.: Q/ <br /> Plumber's Name:(Pnn //LT/ rf. <br /> Plumber's Address(Street,City,State,Zip Code): �� ;L,;) C/ <br /> ;X. <br /> OUNTY/ DEPARTMENT USE ONLYSa itar Permit Fee (in`ludes Groundwater ate Issue IssuingAgen ignature tamps) <br /> Disapproved y Suuhargefee) <br /> pproved ❑OwnerGiveninitial ')�,�AdverseDeterminationONDITIONS OF APPROVAL/ REASONS FOR DISAPPROVAL: <br /> — Salo;ec <br /> DISTflIBUTION. Original to Cauray.one copy To: Safety&Build-1191Dior ion,Owner,Plumbar <br /> saD-639&(K.05l94) _ <br />