Laserfiche WebLink
Safety and Buildings Division <br /> r�'s SANITARY PERMIT APPLICATION Bureau of Building Water Systems <br /> 201 E.Washington Ave. <br /> In accord with ILHR 8305,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 12 x 11 inches in size. �r P <br /> • See reverse side for instructions for completing this application State Sanitary Permit <br /> Number <br /> The information you provide may be used by other government agency programs <br /> [Privacy law,s 15.04(1)(m)]. ❑ ck7it Ievisto previous application <br /> . <br /> State Plan LD.Number r� <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION I S oho — 020 6 <br /> Property Owner Name Property Location <br /> Pc-e> .4�-c7 56-114 g C 1/4,S T ,N, R/ E(or <br /> Property Owner's Mailing Addressr Lot Number Block Number <br /> 1,16 c> ti. aF 01kms <br /> City,StateZip Code Phone Number Subdivision Name or CSM Number <br /> -s' ,eye I( )637.7»/ <br /> Ill. TYPE BUILDING: (check one) ❑ State Owned ❑ ity Nearest Road <br /> Public 1 or 2 FamilyTo Dwelling- No.of bedrooms ❑ age / <br /> Town OF�e�c�/r1,r9�r ry/�3 ,t,1,fa r k Di kP <br /> III. BUILDING USE: (If building type is public,check all that apply) Parcel Tax Number(s) <br /> 1 ❑ Apartment/Condo C_� z/O —3 `- �:2 <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. ❑ Replacement of 4. ❑ Reconnection of 5- ❑ Repair of an <br /> -----System --------System - -- Tank Only ---------- ---Existing System Existing System <br /> ---------- ----------------------- <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 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. 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 /> 3 r1 Feet Feet ' �\ <br /> VII. TANK Capacity <br /> INFORMATION in gallons Total #of Manufacturer's Name Prefab. Site Fiber- plastic Exper \ <br /> New Existin in <br /> Tanks Concrete Con- Steel glass App. <br /> strutted <br /> Tanks Tanks <br /> Septic Tank or Holding Tank Z,90o SOD <br /> Lift Pump Tank/Siphon Chamber 600 � El El I ❑ 0 Q <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 <br /> -Name:(Print) Plumber's Signature:(No Stamps) MP/MPRSW NN Business Phone Number: <br /> Plumber's Address(Street,City,State,Zip Code): <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑Disapproved Sanitary FEB (10 °Groundwater at71ed IssuingA en gn ture(No a ps) <br /> Approved ❑Owner Given Initial W-surchargeFee <br /> Adverse Determination 7 <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(R.0"4) DISTRIBUTION: Original to County.One ropy To: Safety&Buildings Division,Owner,Plumber <br />