Laserfiche WebLink
��� Safety and Buildings Division <br /> t NIK FFi 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 County C 2/.I <br /> than 8112 x 11 inches in size. ✓9 <br /> • See reverse side for instructions for completing this application StateSanItaryP mit uuumber <br /> The information you provide may be used by other government agency programs ❑Check if rUGevision./t/ / <br /> o�lprevious applica _ <br /> (Privacy Law,s. 15.04(1)(m)]. tion <br /> State Plan I.D.NumbeR t/ <br /> I. APPLI ATI N INFORMATION - PLEASE PRINT ALL INF RMATION <br /> Property Owner Name Property Location /� 00 <br /> E 4 1/4 1/4,S ZO T 40 ,N, R t6 E(or)6) <br /> Property Owner's Mailing A dress GGG' of Number Block ryumber <br /> -0.Z35 RD_ �O vrm 11 <br /> City,State Zip Code Ph ne N' ber ubdivisio Name or CSM Num er <br /> W- 830 15 �(6 SI u - Euol4 )-K <br /> II. TY F BU L ING: (check one) ❑ State Owned 0ItVil� Nearest Road <br /> Public 54 1 or 2 Family Dwelling- No. of bedrooms 2 Town OF 0 A vi 0 AID i5cN <br /> III. BUILDINGUSE: (If building type is public,check all that apply) Parcel TaxNumber(s) ,/U) O, aG--03-�,�'� <br /> ect, 11� cL C�i '-{3 <br /> L-/- l CS^ (�8 q <br /> 1 ❑ Apartment/Condo //'� n �� LO ITS OZ 7-00OD <br /> 2 ❑ Assembly Hall 6 ❑ Medica[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. 0 <br /> New 2. Replacement 3. E] Replacement of q E] 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 /> 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.) (Mi_n./in ) Elevation <br /> 30 0 375 375 . 8 `' 1 p 5.0 Feet 99.S Feet <br /> 1. Gallons Per Day <br /> VII. TANK Capacity <br /> INFORMATION in gallons Total #of Manufacturer's Name Prefab. ConSite- Fiber- plastic Exper <br /> New ExistingGallons Tanks concrete Steel glass App <br /> Tanks Tanks svucted <br /> Septic Tank or Holding Tank O 7-5b I E ❑ ❑ El ❑ <br /> Lift Pump Tank/Siphon Chamber I ❑ ❑ ❑ Il ❑ <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:.INA Stamps) MP/MPRSW No.: Business Phone Number: <br /> Ic H u�uu rl 26 S S <br /> Plumber's Address(street,City,State,Z-p Code): <br /> Z'17 �+ 3s- <br /> IX. <br /> SIX. COUNTY/ DEPARTMENT USE ONLY <br /> ❑ iDisapproved Sanitary Permit Fee (indudes Groundwater ate s e Issuing Age tSignat e( <br /> PP <br /> roved <br /> E]Owner GivenlnitiationI15 <br /> P) <br /> Adverse Determnation <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SHO-6398 111.05114) / DISTRIBUTION: Original to County.Une<epy To: Sorely 8 Ruildin,Dimuon,Owneq Plumber <br />