Laserfiche WebLink
Safety and Buildings Division <br /> �tiia.,T■n SANITARY PERMIT APPLICATION Bureau of Building Water System <br /> 201 E.Washington Ave. <br /> In accord with ILHR 83.05,Wis.Adm.Code P_0-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 8 112 x 11 inches in size. oc <br /> • See reverse side for instructions for completing this application State Sanitary Permit Number <br /> The information you provide may be used b other overnmenta enc programs "� <br /> Y 9 agency P 9 ❑Chec d revision to previous applicalion <br /> I Privacy Law,s. 15.04(1)(m)l. <br /> State Plan I.D.Number �0/ ,, //� <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION `7� `T <br /> Property` wnerName Propert cation <br /> / .91- Gert N61/4_Se1/4,S c, Ty0 ,N, R / 7E(or)6T <br /> Property Owner's Mailing Address Lot Numb Block Number <br /> la/ r CedI' d 11 •��. <br /> G ,Stat Zip Code Phone Number Subdivisio Name or CSM Number <br /> � �- _5-y8.3 ( �s <br /> II. UYPEUF BUILDING: (check one) ❑ State Owned El ity 1 Nearest Road <br /> Elae Public 1 or 2 FamilyDwelling- No.of bedrooms To <br /> 1wn OF j6w,O"L) ;0'-L 'e— <br /> III. BUILDING USE: (If building type is public,check all that apply) Parcel TaxNumber(s) <br /> PLIOF <br /> 1 E] Apartment/Condo r 03,1_ — - <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_ L&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 f9Mound 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 1. 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 /> 7 ��5 q/ 1' 49 Feet 0,/ Feet <br /> VII. TANK Capacity <br /> INFORMATION in gallons Total #of Manufacturer's Name Prefab- Con-Site Fiber- Plastic Fxper <br /> New ExistingGallons Tanks Concrete Steel glass App. <br /> strutted <br /> Tanks Tanks <br /> Septic Tank or Holding Tank �o n ❑ ❑ ❑ Q <br /> I ift Pump Tank/Siphon Chamber QD :90 --i 1:1 IJ E] 1:1 El <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 No Sta ps) MP/MPRSW No.: Business Phone Number: <br /> Plumber's Address(Street,City,State,Zip�Code). <br /> '60 oic S /,Y '4s %/^ e—AJ Cid ,c _:5,_ 6 <br /> IX. COUNTY/ DEPARTMENT USE ONLY <br /> E]Disapproved I Sanitary Permit <br /> Fee <br /> /(indudes Groundwater, ate is a Issuing Ag nt Si nature s <br /> fee)V �.tar" <br /> A pproved ❑Owner Given InitialiyAdverse Determination `� <br /> X. CONDITIONS OF APPROVAL/ REASONS FO DISAPPROVAL: 7/ <br /> SIT[)1,398(It.05/94) DISTRIBUTION: Original to County,One copy To- safety 8 Buildings Division,owner,Plumber <br />