Laserfiche WebLink
6-0 CXE-k'%4afety and Buildings Division <br /> NViseonsin SANITARY PERMIT APPLICATION 201 W.Washington Avenue <br /> In accord with ILHR 83.05,Wis.Adm.Code P O Box 7302 <br /> Department of Commerce Madison,WI 53707-7302 <br /> • Attach complete plans(to the county copy only)for the system,on paper not less County <br /> than 81/2 x 11 inches in size. 6FM, <br /> • See reverse side for instructions for completing this application St to Sanitary Permit Number w <br /> 33 s <br /> Personal information you provide may be used for secondary purposes ❑Check it revision to pre ious application <br /> [Privacy Law,s. 15.04(1)(m)]. <br /> State Plan I.D.Number <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INF RMATI N <br /> Property Owner Name Property Location <br /> 1/4 1/4,S 1#3 T40 N, R S E(or nW <br /> Property Owner's Mallin Address Lot Number g <br /> ZS(.36 Raa )Zp- .L. <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> 45 S30 ( 1S )ZS -_ C$* Dot z 3 <br /> II. TYPE L 1 : (check one) ❑ State Owned o City <br /> dd �! Nearest <br /> Road ��77yy�� <br /> 171 3 ❑ Village SAfW5Qd ID E Rp <br /> Public 1 or 2 FamilyDwelling-No.of bedrooms own of <br /> III. BUILDING-USE: (If building type is public,check all that apply) Parcel TaxNumber(s) <br /> 1 ❑ Apartment/Condo 4Zl_�r Of 3!?4o <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.XReplacement 3. E] Replacementof 4. E] Reconnection of 5_ [:] Repair of an <br /> _____Sntem ____ Sntem _____ 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 ❑Mound 30 C]Specify Type 41 E]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 /> VL ABSORPTION SYSTEM INFORMATION: <br /> 2. Absorp.Area 13. Absorp.Area 4. Loading Rate 15. Perc. Rate 16. System Elev. 7. Final Grade <br /> Required(sq.ft.) Propposed(sq.ft.) (Gals/day/sq.ft.) (Min./inch) Elevation <br /> 643 !0 48 . 't (o l l Feet it-to Feet <br /> 1. Gallons Pe 77 <br /> TANK Capacit VII. FORMATION in llons Gallons Tanks ' Concrete site 9I, App. <br /> g Manufacturer's Name Con- steel Pber- lastic p <br /> New Existin structed <br /> Tanks T nks C <br /> Septic Tank or Holding Tank10001 — QQO t CKFI W ❑ ❑ ❑ ❑ ❑ <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) Plumber's Signature:(No S mps) MP/MPRSW No: Business Phone Number: <br /> c q R Pt(Cl S e 2!0 1 tS• �lo6w S <br /> P mber's Address(Street, ity,State,Zip Code): <br /> 1-7 D W S F-S,51� 1,41. 54.%q3 <br /> IXJ COUNTY/DEPARTMENT USE ONLY <br /> 10 Disapprove( Sanitary Permit Fee (IndudesGoundwater ate ssue Issuing entSignature(No Stamps) <br /> roved surcnarge fee) <br /> pp El Owner <br /> -16-% v <br /> Adverse Determination <br /> . C NDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(R.11197) DISTRIBUTION: Original to County.One copy To: Safety 8 Buildings Division,Owner,Plumber <br />