Laserfiche WebLink
C,)2cc)rn,,Or <br /> Safety and Buildings Division <br /> - SANITARY PERMIT APPLICATION 201 W.Washington Avenue <br /> NV'isconsin P O Box 7302 <br /> Department of Commerce In accord with Comm 83.05,Wis.Adm.Code Madison,WI 53707-7302 <br /> • Attach complete plans(to the county copy only)for the system,on paper not less County � <br /> than 812 x 11 inches in size. 3 <br /> • See reverse side for instructions for completing this application St4rteSanitar Permit Num9be�r/�1� <br /> Personal information you provide may be used for secondary purposes ❑Check if re : O P application <br /> (Privacy Law,s. 15.04(1)(m)1. State Plan I.D.Numb <br /> I. APPLICATION INFORMATION- PLEASE PRINT ALL INF ORMATI N <br /> Propert Owner Name L P opert Location <br /> 4 1/4,Sga T 440 ,N,R �(o E(or <br /> Prope y Owner's ailing Address Lot Number Block Number <br /> c U 5 t <br /> City,State ZT Code Phone Number Subdivision Name or CSM Number <br /> gn M rJ 1.2501(6Q )43CI-134( <br /> II. TYPE OF BUILDING: (check one) ❑ State Owned a City Nearest Road <br /> Public 1 or 2 Family Dwelling-No.of bedrooms 3 " rowan OF 139%,11,01004 <br /> 111. BUILDINGUSE: (If building type is public,check all that apply) Parcel TaxNumber(s) <br /> 1 ❑ Apartment/Condo 1 020 O4 100 <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. 1$ Replacement 3_ ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an <br /> Sy/stem _ 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 /> 11Seepage Bed 21 E]Mound 30[-]Specify Type 41 ❑Holding Tank <br /> 12 M 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 S. Perc. Rate 6. System Elev. 7. Final Grade <br /> 4-5a Reqiiir�ed3(sq.ft.) ProposedAC�(sq.ft.) (Gals/di y/sq.ft.) (M!ink/inch) El 04t <br /> (� qs •� Feet Feet <br /> Ca aclt <br /> VII• TANK FORMATION in gallons Total #of Manufacturer's Name Prefab. Con- Steel Site Fiber- PA <br /> lasticExper <br /> New Existin Gallons Tanks concrete structed glass App.p- <br /> il <br /> Tanks T nks <br /> Septic Tank or Holding Tank o El El1:1 ❑ El <br /> Lift Pump Tank/Siphon Chamber ❑ ❑ ❑ I ❑ ❑ ❑ <br /> Vill. 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:(N tamps) MP/MPRSW No.: Business Phone Number: <br /> c►1AW 46M42--2S9SI 71s, W- 415-7 <br /> Plu ber's Address(Street,City,State,Zip Code): <br /> 2"1-7 too 14 w W WI. 54 q3 <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑Disapproved S nitary Permit includes Groundwater ate IssuedIssuing A n igna ure( S ps) <br /> Surcharge <br /> rcharge Fee) <br /> proved 1_1Owner Given Initial <br /> Adverse Determination Tr <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(R.4199) DISTRIBUTION: original to County,One copy To: Safety a Buildings Division,Owner,Plumber <br />