Laserfiche WebLink
Safety an ui dings Divi�� <br /> ` SCOnS%n SANITARY PERMIT APPLICATION 201 W.Washington Avenue <br /> P O Box 7302 <br /> Department of.Commerce In accord with Comm 83.05,Wis.Adm.Code Madison,WI 53707-7302 <br /> • Atthch complete plans(to the county copy only)for the system,on paper not less CqUnty <br /> than 8 112 x 11 inches in size. t� <br /> • See reverse side for instructions for completing this application State SanitaryPe t N b / <br /> —y//q� (p j�j'� (� <br /> Personal information you provide may be used for secondary purposes ❑Check it revision lJou a plicatidn w <br /> [Privacy Law,s. 15.04(1)(m)]. State Plan I.D.Number <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INE ORMATI N <br /> Prop rt Owner Name Pro ocati in JF <br /> Prop 1/4,S 3� T qp N, R 6 E(o W <br /> I <br /> Property Owner's Mailing Address Lot Number Block Number <br /> O I nl 5T- <br /> Cit ,State Zip Code Phone Number Subdivision Name or CSM Number <br /> p,E D21 ( I 2ACAES <br /> 11. TYPE OF BUILDING: (check one) ❑ State Owned 0 r-ity Nearest Road <br /> ❑ Village n <br /> El Public 1 or 2 FamilyDwellingTwn <br /> -No.of bedrooms Z Town of coW <br /> 111. BUILDING USE: (If building type is public,check all that apply) Parcel TaxNumber(s) <br /> 1 ❑ Apartment/Condo 020 +3% 01 -700 <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. E] Repair of an <br /> 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 /> 12theepage 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/day/sq.ft.) (Min./inch) Elevation <br /> O GI , s ^—� -0 Feet 6• Feet <br /> TANK Ca a it <br /> VII INFORMATION in gallons Total <br /> Tanks Manufacturer's Name Conc Prefab <br /> Coro Steel glass Plastic Appr. <br /> New Existin structed <br /> Tanks Tanks <br /> Septic Tank or Holding Tank1956-:=F - ZZ ❑ ❑ ❑ ❑ ❑ <br /> Lift Pump Tank/Siphon Chamber ❑ ❑ ❑ ❑ ❑ ❑ <br /> VIII. RESPONSIBILITY STATEMENT <br /> I,the undersigned,assume responsibility for installation of the onsite sewage system shown on the attached plans. <br /> PIber's Name:(Print) Plumber's Signatur :( tamps) MP/MPRSW No: Business Phone Number: <br /> 6�irlt �ccl Z�S$s/ IS-g66 s'' <br /> P umber's AddressStree City,State,Zip Co ): <br /> Wl- <br /> _SW &JIM2 <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑Disapproved SapitaryPermitFee (includes Groundwater ate IssuedIssuing nature No St s) <br /> �cpproved / .75 crib surcharge 7 <br /> ❑Owner Given Initial <br /> Adverse Determination ' <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(R.4/99) DISTRIBUTION: Original to County.One copy To: Safety a Buildings Division,Owner,Plumber <br />