Laserfiche WebLink
° Safety and Buildings Division <br /> SANITARY PERMIT APPLICATION Bureau of Building Water Systems <br /> 201 E.Washington Ave. <br /> J 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 County <br /> than 8 tib x 11 inches in size. <br /> • See reverse side for instructions for completing this application State Sanitary PPeeruurmit Number <br /> The information you provide may be used by other government agency programs ❑Check it revision to previous application <br /> [Privacy Law,s. 15.04(1)(m)I. State Plan I.D.Number <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION <br /> Property Owner a Property Location <br /> b'ri tA,ZtGIpo 114 1/4,S 3 T Zj N, R 1 4� Ear)W <br /> Property Owner's Mailing Address IF Lot Number Block Number <br /> II,1 t-7- 11 <br /> City,State l Zip Code hone Number Subdivision Name CS Number �6 $6rl <br /> VV <br /> II. TYPE'OF BUILDING: (check one) ❑ State Owned ❑ CitNearest <br /> v-, Nearest Road <br /> ❑ Public 1 or 2 FamilyDwellingEl Vill- No.of bedrooms 13 own of K t:. ��'-L.bkKE <br /> III. BUILDING USE: (If building type is public,check all that apply) Parcel Tax Number(s) O( 31LI 2 —03 --7`0 <br /> 1 F1 Apartment/Condo 31- 14-03 -63710 v <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❑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. Pert. Rate 6. System Elev. 7. Final Grade <br /> Required(sq.ft.) Proposed(sq.ft.) (Gal(A <br /> sq.ft.) In in Elevation <br /> (A+3 '1$4,7-5 ,$ w 1� $1Q.0 Feet qS,c Feet <br /> Capaut <br /> VII. INFORMATION in allons Total #of Manufacturer's Name Prefab Site Steel Fiber- Exper <br /> Gallons Tanks concrete lass Plastic A <br /> New Existin strutted g pp <br /> Tanks Tanks <br /> Septic Tank or U-1-A, *w„p- 1000 ❑ ❑ ❑ ❑ ❑ <br /> (i amber 3 1$l7e9r," 17 Q FtELp SKS) 9 ❑ ❑ ❑ ❑ ❑ <br /> VIII. RESPONSIBILITY STATEMENT <br /> I,the undersigne("L*e responsibility for instAllation of the onsite sewage system shown on the attached plans. <br /> Plumber's ItflBtEXCAVATI •ssigna re:(No Stamps) Ir/MPRSWNo.: Business Phone Number: <br /> Ni M Une Rd. q871 <br /> Plumber's Address IffiTt"aCode): <br /> IX. COUNTY/ DEPARTMENT USE ONLY <br /> ❑Disapproved Sanitary Permit Fee (includes Groundwater ate ssue ssuingAgent gnatur {NoS s) <br /> roved CdJ surchargeree) <br /> p ❑Owner Given Initial f�d `/y <br /> Adverse Determination <br /> X. CO DITIONS OF APPROVAL/7S ONS FOR DISAPPROVAL: <br /> SeD-6398(R.05/94) DISTRIBUTION: Original to Courtly.One Copy To: Sefety&Building,Dim>mn,owner,Plumber <br />