Laserfiche WebLink
a! � Safety and Buildings Division <br /> SANITARY PERMIT APPLICATION Bureau of Building Water Systems <br /> 201 E.Washington Ave. <br /> In accord with ILHR 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 count _ <br /> than 8 112x 11 inches in size. :; - <br /> • See reverse side for instructions for completing this application State Sanitar8mry Permit Nuer 1�b <br /> :3 1 <br /> The information you provide may be used by other government agency programs E]Check it revision to previous application v` <br /> [Privacy Law,s. 15-04(1)(m)]. State Plan I.D.Number >>�� <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION <br /> Property OwProperty Location <br /> r er Nam_AA e r 1/4 1/4,S 3y T j? ,N, R 1,9, E(or)�V <br /> Property Owner's Mailing Address n het A{uw+}fer'�` Block Number <br /> City,StateZip Code Phone Number Subdivision Name or CSM Number <br /> r,f;✓ N c,�-i 717 .5y&5la I( ) <br /> II. TYPE OFBUILDING: (check one) ❑ State Owned ❑ City Nearest Road f <br /> ❑ Village n <br /> Public 1 or 2 Family Dwelling- No.of bedrooms pTown OF 0,J L)C/s L I <br /> III. BUILDING USE: (If building type is public,check all that apply) Parcel Tax Number(s) 2 <br /> 1 ❑ Apartment/Condo �� ods✓ d b �0 <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 ❑Mound 30❑Specify Type 41 ❑ Holding Tank <br /> 12 Weepage Trench 22❑In-Ground Pressure /� L 42❑Pit Privy <br /> 13 E]Seepage Pit _!^' '� //�t��°� 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) q Eleva <br /> C34 C> C X7.5 r / k 2 Feet M Feet <br /> Capacity <br /> VII. TANK in gallo S Total #of Prefab. Site Fiber- Exper <br /> INFORMATION Gallons Tanks Manufacturer's Name Concrete con- Steel glass Plastic App <br /> New ExiStin strutted <br /> Tanks Tanks <br /> Septic Tank or Holding Tank 7`J—O .50 Ej El <br /> L ift Pump Tank/Siphon Chamber 54;'0 sc.>0 ® El 11 0 <br /> VIII. RESPONSIBILITY STATEMENT <br /> I,the undersigned,assume responsibility for installation of the onsite sewage system shown on the attached plans. <br /> Plumber'sName:(Pnn,� Plumber's Signature. MP/MPRSWNo.: Business Phone Number: <br /> t��l e /V y���✓m 6 o�Y9 ' 7�Z�6 <br /> Plumber's Address(Street,City,State,Zip Code): <br /> IX. COUNTY/ DEPARTMENT USE ONLY <br /> ❑Disapproved Sanitary Permit Fee (In`�udcsGroundwater ate Issue IssuinMentSigwtur ( Stamps) <br /> roved I�T h�.-�Sur<harge fee) &6A <br /> �_ A <br /> pp ❑Owner Given Initial l�--JJIJI a�� r/11 <br /> Adverse Determination i Ali <br /> X. CONDITIONS OF APPROVAL/ REASONS FOR DISAPPROVAL: <br /> ShD-6398(K.05194) DISTRIBUTION: Original in County,One utI'y To: SAety 8 Building,0m,'un,Owner,Plemwr <br />