Laserfiche WebLink
Safety and Buildings Division <br /> Visconsin <br /> SANITARY PERMIT APPLICATION 201 W.Washington Avenue <br /> P O Box 7302 <br /> Department of Commerce In accord with Comm$3.05,Wis.Adm.Code Madison,WI 53707-7302 <br /> • Attach complete plans(to the county copy only)for the system,on paper not less County <br /> than 8 12 x 11 inches in size. <br /> • See reverse side for instructions for completing this application StSfe sanitary Pe(it rut�n�p� <br /> Personal information you provide may be used for secondary purposes ❑Check it revision to previous application U, <br /> [Privacy Law,s. 15.04(1)(m)I. State Plan I.D.Number ` , <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INF RMATION OfllV/ <br /> Property Owner Pjame PFopertylocationr T 41 N, R ( <br /> NfILA] ` 1/a S '1 E(or) <br /> Pr Ow er's ilin Address Lot Number Block Number <br /> City,Sta a 2i ode ( ; ;um er Subdivision Name'�o�t M Number <br /> BUILDING: (check one) ❑ State Owned it Nearest Road <br /> ❑ Village <br /> Public 1 or 2 FamilyDwelling- No.of bedrooms 2— own of ISS 7 <br /> III. BUILDING USE: (If building type is public,check all that apply) Parcel TaxNumber(s) <br /> 7 t> <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) ll_ New 2. E] Replacement 3, E] Replacement of 4. E] Reconnection of 5. E] 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 /> 11Seepage Bed 21 E]Mound 30 E]Specify Type 41 C]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. 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) /� E evation <br /> p' 32 q,+ I Feet -Q Feet <br /> VII. TANK Ca acct Site <br /> in gallons Total #ofMrer's Name Prefab. Con- Steel Fiber- plastic Exper. <br /> Manufacturer's INFORMATION New Existin Gallons Tanks Concrete strutted glass App. <br /> Tanks Tanks <br /> Septic Tank or Holding Tank <br /> Lift Pump Tank/Siphon Chamber El ❑ ❑ El E <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:(Pri ) r Plu r' Signature( Stamps) MP/MPRSW No.: Business Phone Number: <br /> A90 Irl'_/ ZZSSSI IS <br /> PI ber's Address(Street,City,S te,Zip Code <br /> 1. <br /> IX. COUNTY/DEPARTM UNT USE ONLY <br /> ❑Disapproved Sanitary Permit Fee (Includes Groundwater ate IssuedIssuingUgeSigna re No s) <br /> rproved ge Fee) <br /> p ❑Owner Given Initial /, AS <br /> Adverse Determination V <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> DISTRIBUTION: Original to County.One copy To: Safety a Buildings Division,Owner,plumber <br /> SBD-6396(R.4/99) <br />