Laserfiche WebLink
w/ ' �� Safety and Buildings <br /> ,-----��t11tITA PERMIT APPLICATION �1 ec,�� Bureau a Building Water Systems <br /> 2.O E.Washington Ave. <br /> In accord with(LHR 83 05,Wis.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 8112 x 11 inches in size. e / 6 <br /> • See reverse side for instructions for completing this application State Sanitary Permit Number <br /> The information you provide may be used by other government agency programs Check visil previous application <br /> (Privacy Law,s. 15.04(1)(m)I. State Plan I.D.Numberf , <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION N <br /> Propert Owner Name Property Location (3-,4,Z/} 1/4 1/4,S T $10 ,N, R 1JV S E(o W <br /> Property Owner's Mailing Address Lot Numbed L Block Number <br /> O '— <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> -- <br /> II. TYPE Of BUILDING: (check one) ❑ State Owned 0ut� L Nearest Road <br /> Public 1 or 2 FamilyDwelling- No. of bedrooms & vown OF /`hU�SaN <br /> III. BUILDING USE: (If building type is public,check aIIthat apply) Parcel TaxNumber(s) <br /> 1 ❑ Apartment/Condo O/o?— ya/G <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 /> ---- 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 E]Mound 30[-]Specify Type 41 ❑ Holding Tank <br /> 12 E] eepage 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 /> yS--49 Required(sq. ft.) Pro osed(sq.ft.) (Gals/day/sq.ft.) (Min./inch) �� Elevation <br /> 170l.> led S" Feet 8,6 Feet <br /> VII. TANK Capacity <br /> In gallons Total #of Prefab.- Site Fiber- plastic Exper <br /> INFORMATION New Existin Gallons Tanks Manufacturer's Name concrete con- steel glass App. <br /> strutted <br /> Tanks Tanks <br /> Septic Tank or Holding Tank El E <br /> Lift Pump Tank/Siphon Chamber 6lgr� . El El El El El <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 ps) MP/MPRSW No.: Business Phone Number: <br /> le <br /> Plumber's Address(Street,City,State,�ip Code): <br /> T- //'G iv e�.Z- <br /> IX. COUNTY/ DEPARTMENT USE ONLY <br /> 7�t ❑Disapproved Sanitary Permit Fee Ondudes6roundwater aterj/;,suu,ed lissuin A ntSi nat Stamps) <br /> " 'r roved �L�wc Siafge tee) �.J /O <br /> P ❑Owner Given Initial _ / <br /> Adverse Determinationrft;01 <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SNI)-6398(R.BS/94) DISTRIBUTION. Original to enunly.One«py To: Safety&Buildings Diauion,Owner,Plumter <br />