Laserfiche WebLink
r <br /> Safety and Buildings ivisio�n <br /> SANITARY PERMIT APPLICATION Bureau of Building Water System! <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 <br /> than 8 1/2 x 11 inches in size. <br /> • See reverse side for instructions for completing this application State Sanitary <br /> (P/Peermit Number <br /> The information you provide may be used by other government agency programs ❑Ch d revision to previous application <br /> [Privacy Law,s. 1 5.04(1)(m)]. <br /> State Plan I.D.Number <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION <br /> Property Owner Name —}� Property Location <br /> G /0� c� 1/4 � 1/4,S j7 T ;/0,N, R � E(or <br /> Property Owner's ailing Address Lot Number Block Number <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> / <br /> II. TYPE F BUILDING: (check one) E] State Owned El City Nearest Ro d/ <br /> Public 1 or 2 FamilyDwelling-No.of bedrooms >2 [ TownOF J r^ k1,a %�� li✓ u �/o .✓ �/ , l / <br /> III. BUILDING USE: (If building type is public,check all that apply) Parcel Tax Number(s) <br /> 20-9155-01 900 <br /> 1 ❑ Apartment/Condo <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. jS Replacement 3. ❑ Replacement of q ❑ Reconnection of 5. ❑ Repair of an <br /> ------System ________System __ __ TankOnly_________ Existing System ___ __ Existing System <br /> B) ® A Sanitary Permit was previously issued. Permit Number 10677 Date Issued 4/13/88 <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 p 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) Elevation <br /> 1---yD d 425 432 -- 2 97.6 Feet 99-1 Feet <br /> Capact <br /> VII. TANK in gallons Total #of Site <br /> INFORMATION Gallons Tanks Manufacturer's Name Concrete Con- Steel Fiber- <br /> ass Plastic App. <br /> New Existinstrutted <br /> Tanksl Tanks <br /> Septic Tank or Holding Tank S°�� / ,jam-'/-��;/ <br /> Lift Pump Tank/Siphon Chamber <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) rlu <br /> mber'sSignature:(No Stamp ) MP/MPRSW No.: Business Phone Number: <br /> Plumber's Address(Street,City,State,Zip Code): <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑Disapproved SanititryPermrtFe (includes Groundwater ate ue Issuing Age Si natu Stamps) <br /> *pproved E]Owner Given Initial /�O urcharge Fee) <br /> Adverse Determination / <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(R.0SN4) DISTRIBUTION: Original to County,One copy To: Safety B Buildings Division,Owner.,Plumber <br />