Laserfiche WebLink
Saf <br /> ty and Buildings <br /> SANITARY PERMIT APPLICATION 201eE.Washington Avve.'sion <br /> Visconsin In accord with[LHR 83A5,Wis.Adm. P.O.Box 7969 <br /> Code <br /> Department of Commerce Madison,WI 53707-796 <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. <br /> • See reverse side for instructions for completing this application StateSSaanitary Permit NumlSer <br /> yo <br /> The information you provide may be used by other government agency programs E]Check ivintoto previous application IN <br /> [Privacy Law,s. 15.04(1)(m)). '� <br /> State Plan I.D.Number <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION 1 AAA= <br /> Prop YO r Name Property Location <br /> / f % t/a t/a,S a� T ,N, R/L(f `W <br /> Prop yOwnerIs lingAdc�ress/ Lot Number Block Number <br /> Ci State //. Zip Coe Phone Number Subdivision Name or CSM Number <br /> � 7 ( > S <br /> 1. BUILDING: (check one) ❑ State Owned Ej 'ty Nei st R�d�/ <br /> Public 1 or 2 FamilyDwelling- No.of bedrooms ° Towan OF /L00/ � �`e�` lv� <br /> 111. BUILDINGUSE: (If building type is public,check all that apply) Parcel TaxNumber(s) <br /> 1 E] Apartment/Condo <br /> Oo2 6 — -d6 - )1`1G <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. E] Replacement 3. [:3 Replacementof 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 /> 11 ❑Seepage Bed 21 ❑Mound 30❑Specify Type 41 ❑Holding Tank <br /> 12((Seepage Trench 22❑In-Ground Pressure 42❑Pit Privy <br /> 13 E]Seepage Pit / �� d"d* � �� C43 E]Vault Privy <br /> 14 System-In-Fill � (.0 <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 /> �1�0 Required(sq.ft.) Proposed(sq.ft.) (Galslday sq.ft.) (Min./inch) Elevati n <br /> ' V1 � eet 'r FFeet <br /> Capaelt Site <br /> VII. FORMATION in allons Gallons Tanks Manufacturer' Name co�c eLe Con- steel yless Plastic APPr <br /> New Existin strutted <br /> Tanks Tanks <br /> 99p–t—icr Holding Tank ❑ ❑ ❑ ❑ ❑ <br /> lift Pump T /Siphon Chamber ❑ ❑ ❑ ❑ ❑ <br /> VITURESPONSIBILITY STATEMENT <br /> I,the undersigned,assume responsibility for installation of the onsite sewage system shown on the attached plans. <br /> Plumbe 's Name:(PrinIL Plumb MP/MPRSW No.: Business Phone Number: <br /> Al, <br /> V 71-P, <br /> Plum is At a.rpfis(Street,City,State,Zip Code): <br /> d eo�'_soe- <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑DisapprovedS itary Permit Fee (includes Groundwater ate IssuedIssuing Agent Sign ture(N S <br /> (Approved ❑ rcnarge Fee) <br /> Owner Given Initial � ( lYj <br /> Adverse Determination J' <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(R.11/96) DISTRIBUTION: Original to county.One copy To: Safety 8 Buildings Division,Owner,Plumber <br />