Laserfiche WebLink
� gyp, <br /> ^ a: ^ Safety and Buildings Division <br /> r.t■■-r.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.O.Box 7969 <br /> Madison,WI 53707-7969 <br /> • Nttach complete plans(to the county copy only)for the system,on paper not less Co my / <br /> than 8 1/2 x 11 inches in size. n.e�T C7 <br /> • See reverse side for instructions for completing this application State Sanitary Permit`899 r! -7 <br /> Number� <br /> The information you provide may be used by other government agency programs ❑check it revision to previous application <br /> I Privacy Law,s. 15.04(1)(m)]. <br /> State Plan I.D.Number <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION 1 7 — c_2Q S <br /> Prop rty caner Nam /� Property Location <br /> Vi 0 : `('u'P(� 161/4 NW 1/4,s3(, T 3 <br /> Property Owner's Mating Address Lot Number Block Number <br /> 1 30 <br /> Cit State Zip Code Phone Number Subdivision Name or CSM Number <br /> 2 c�yt li �2 -St/003 (719 > X73-y S i Z e 3 3 <br /> II. TYPE OF BUILDING: (check one) ❑ State Owned E] it <br /> E] (aqe Nearest Road <br /> To❑ Public 1 or 2 FamilyDwelling- No. of bedrooms Town of SQ.n q <br /> III. BUILDING USE: (If building type is public,check all that apply) Parcel TaxNumber(s) <br /> 1 ❑ Apartment/Condo I M 1 163 0 S'10 <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. X 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 ❑Mound 30❑Specify Type 41 SK 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 S. Perc. Rate 6. System Elev. 7. Final Grade <br /> Feet <br /> Required (sq. ft.) Proposed(sq.ft.) (Gals/day/sq. ft.) (Min./inch) Elevation <br /> Feet <br /> TANK Capact VII INFORMATION in gallons Total #of Manufacturer's Name Prefab. Con Steel Fiber- plastic Exper_ <br /> New Existin Gallons Tanks Concrete glass App. <br /> Tanks Tanks strutted <br /> SepticTank Holding Tank 7-600 (,eSP ❑ ❑ ❑ ❑ ❑ <br /> t ift Pump Tank/Siphon Chamber FX10 ❑ ❑ ❑ ❑ ❑ <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 PI"tuber's Signat e: o Stamps) MP/MPRSW No.: Business Phone Number: <br /> (S o-ec: r aa- 66- o <br /> lumber's Address treet,City,S tde,Zip Codey): <br /> r <br /> t <br /> IX. COUNTY/ DEPARTMENT USE ONLY <br /> ❑Disapproved Sanitary Permit Fee (IndudesGrovndwater ate Issue Issuing Agen (gnat a(N ps) <br /> Approved ❑Owner Given Initial <br /> r6 na`9e`ee1 _ � <br /> Adverse Determination <br /> X. CONDITIONS OF APPROVAL/ REASONS FOR DISAPPROVAL: <br /> SHO-6398(H.OS/94) DISTRIBUTION: Original to(aunty,ane copy To: Safety 8 RuiI,fings Div,-.ion.Owner,Plumber <br />