Laserfiche WebLink
� i. C�tiC�, <br /> �ISC011S%D SANITARY PERMIT APPLICATION Safety and Buildings Division <br /> 201 E.Washington Ave. <br /> Department of Commerce In accord with ILHR 83.05,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 Count <br /> than 8112 x 11 inches in size. /' aaa�y$ <br /> • See reverse side for instructions for completing this application State Sanita/ryy�Permit/Number <br /> The information you provide may be used by other government agency programs -33 `"c �l o <br /> (Privacy Law,s. 15.04(1)(m)). ❑Check rt revision to previous application <br /> State <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INPlan I.D.Number <br /> tl <br /> FORMATION r7er pt <br /> Prope%rt Owner Name Property Location v <br /> O ���/ 1/4 1/4,5 Tye ,N, fj/5'—E(or <br /> Property Owner's Mailing Address Lot Number <br /> 3 $— a BIecP�t+rrrber <br /> City,State ve ZCode Phone Number Su a or CSM Number G <br /> b ./L.. P9 . c m <br /> II. Y E 0 BUILDING: (check one) State Owned . ❑ City❑ C] Village Nearest Road <br /> Public 1 or 2 FamilyDwelling-No.of bedrooms� Town OF ,q c1-5 o.C� <br /> /� ( C� e,// <br /> III. BUILDING USE: (If building type is public,check all that apply) Parcel Tax Number(s) <br /> 1 ❑ Apartment/Condo Q — V.�?/` D :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. EZINIew 2. ❑ Replacement 3_ Re Replacementof <br /> __ystem S stem ❑ p 4. [:] Reconnection of 5. F] RepingSyn <br /> _____ <br /> _________YTank-Only _ Existing System Existting 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 §tSeepage Bed 21 ❑Mound 30❑Specify Type 41 <br /> 12 E]Seepage Trench 22 E]In-GroundPressure [:]Holding Tank <br /> 13❑Seepage Pit 42❑Pit Privy <br /> 14 ElSystem-In-Fill 43 E]Vault Privy <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 /> S'sfj Required(sq. ft.) Proposed(sq.ft.) (Gals�a /sq.ft.) (Min./inch) cy 6/ 5/Elevation <br /> 1 G <br /> VII. TANK Capacity / Feet 7A Feet <br /> INFORMATION in gallons Total #of Prefab site Fiber- <br /> Gallons Tanks Manufacturer's Name Con- Plastic Exper <br /> New Existin Concrete strutted Steel glass App. <br /> Tanks Tanks .2 <br /> Septic Tank or Holding Tank dOQ ®®� S ,r. ❑ 0 <br /> Lift Pump Tank/Siphon Chamber 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 Name:/(Print) ^ P <br /> lumber's Signature:(No mps) MP/MPRW No.: Business Phone Number: / <br /> e– <br /> Plumber's Ar dress(Street,city,state,Zi <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑Disapproved Sanitary Permi Fee (Includes Groundwater atessue ! Issuing ge t Siiqnaure(N StApproved [IOwner Given Initial Surcharge Fee) <br /> Adverse Determination 6 j <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: GGG <br /> SBD-6396(R.11/96) DISTRIBUTION: Original to County,One copy To: Safety a Buildings Division,owner,plumber <br />