Laserfiche WebLink
Safety and Buildings Division <br /> SANITARY PERMIT APPLICATION Bureau of Building Water Systems <br /> In accord with ILHR 83 05,Wis.Adm.Code 201 E.Washington Ave. <br /> 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 1/2 x 11 inches in size. <br /> • See reverse side for instructions for completing this application State Sanitary Permit Num cerT ($ <br /> The information you provide may be used by other government agency programs ❑Chaff revl)previous application <br /> IPrivacy Law,s. 15-04(1)(m)]. <br /> State Plan I.D.Number <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION <br /> Property Owner Name property Location IF <br /> fie - �S I Z T ,N, E(or) la <br /> Property Owner's Mailing AddressLot Number Block Number <br /> 1316 -Bur RP ill Gti Lo+b <br /> City,StateZip Code Phone Number Subdivision Name or CSM Number <br /> m•► 5_541 ( 1Z > 3 V13 P.-.705- <br /> 11. TYPE OF BUILDING: (check one) ❑ State Owned ❑ CityNearest Road <br /> Public 1 or 2 FamilyDwelling-No. of bedrooms ❑ vilwn lageOF >CO* LAKE <br /> o <br /> III. BUILDING USE: (if buildingtypeispubhc,checkallthatapply) Parcel TaxNupmber(s) /> q <br /> 1 ❑ Apartment/Condo D�a ` `(�—�� l 6 <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. E] Replacement of 4. E] Reconnection of 5. E] Repair of an <br /> ______System --------System Tank-Only______________ _ y---------------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 Distribt on Pressurized Distribution Experimental Other <br /> 11 J'Seepage Bed I_J 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- A bsorp.Area 4. Loading Rate S. Perc. Rate 6. System Elev. 7. Final Grade <br /> Required (sq. ft.) Proosed(sq. ft.) (Gals/day/sq. ft.) (Min./inch) Elevation <br /> 30c) 00 DO or' A 47413 Feet 'G,O Feet <br /> VII. TANK Capacity <br /> INFORMATION in gallons Total #of Manufacturer's Name Prefab Site Con- Fiber- Plastic Exper. <br /> New ExistingGallons Tanks concrete Steel glass App. <br /> strutted <br /> Tanks Tanks <br /> Septic Tank or40&WrrTg-F7nk O /ZSO ❑ ❑ <br /> Lift Pump Tank 4i 7 <br /> 1:1 ❑ ❑ El 11 <br /> VIII. RESPONSIBILITY STATEMENT <br /> I,the undersigne a responsi Ii for i tallat' n of the onsite sewage system shown on the attached plans. <br /> Plumber's N@ • EXCA ATI ber' nature: o Stamps) /MPRSW No.: Business Phone Number: <br /> �w��'��N� �!LIM Una <br /> Rd as r <br /> Plumber's Address( Code): <br /> �i� 7492 <br /> IX. COUNTY/ DEPARTMENT USE ONLY <br /> ❑Disapproved Santar Pe Fee (I" odes erounde,ater ate.ssue Issui ant Si afur N amps) <br /> rOVed /� charge Fee) <br /> pP ❑Owner Given Initial <br /> Adverse Determination <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SHD-6398(It.05/94) DISTRIBUTION: Original ro(ounl y.One u)Py Ta: Safety 8 BuilJing>nivn ion,owner,Plumber <br />