Laserfiche WebLink
Safety and Buil Ings Division <br /> �•{Zr>.R SANITARY PERMIT APPLICATION Bureau of Building Water Systems <br /> 201 E.Washington Ave <br /> In accord with ILHR 83 05,Wis.Adm.Code P.O.Box 7969 <br /> Madison,V i 53707-7969 <br /> • Attach complete plans(to the county copy only)for the system,on paper not less County <br /> than 8 1/2 x 11 inches in size. �ri�,v�rj ` 3�p <br /> • See reverse side for instructions for completing this application State Sary Permit Nu5 <br /> The information you provide may be used by other government agency programs Elcheck it revision to previous application <br /> [Privacy Law,s. 15.04(1)(m)l. State Plan I.D.Numbgr/ <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION <br /> Property Owner Name Property Location <br /> �j [L 6L 1/45— 1/4,5 8 T"i40 ,N, R /4 E(or <br /> Propert Owner's Mailing Address Lot Number Block Number <br /> If I$ DW77-XIVQ RD t <br /> City,State Zip Code Phone Number Subdivision Name or CSM Numb)4 <br /> lloQ <br /> �1PR4-I Rl&� ma, ss 3 1(41;?) b r cs V146 , . <br /> II. TYPE OF BUILDING: (check one) ❑ State Owned ❑ City Nearest Road <br /> Public 1 or 2 FamilyDwelling- No.of bedrooms �_ ° Town of SCo7�' Loc' «� 120 <br /> III. BUILDING USE: (If building type is public,check allthatapply) Parcel TaxNumber(s) <br /> 1 ❑ Apartment/Condo <br /> o z8-410 as 5'BO <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. E] Replacement of 4_ E] Reconnection of 5_ E] Repair of an <br /> ystem System Tank Only Existing SystemExisting 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�?Reepage Bed 21 E]Mound 30 E]Specify Type 41 E]Holding Tank <br /> 12❑ eepage 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 /> �D© Requi�d ( ft.) Proposed(sq.ft.) (Gals/day/sq. ft.) (Min./inch) IPI=48-i d Elevation �r <br /> 2` 7 ft2=4711 I Ck=)6Feet <br /> VII. TANK Ca acit <br /> In gall0 5 Total #ofPrefab. Site Fiber- plastic Exper <br /> INFORMATION New Existin Gallons Tanks Manufacturers Name Concrete st noted Steel glass App. <br /> Tanks Tanks <br /> Septic Tank or Holding Tank 7501 1 7570 1El ❑ Fl 1:1 1]Lift Pump Tank/Siphon Chamber Y ❑ ❑ ❑ ❑ ❑ ❑ <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) Plum =sat (No S mp rP/MPRSW NO.: Business Phone Number: <br /> �DiV L7> E J 1�-�l�' 2zl4 Zo z�;')- 2q41- 35-0 <br /> Plumber's Address(Street,City,State,Zip Code). <br /> l6-7,(3 S. 57A7- Ro 35 <br /> IX. COUNTY/ DEPARTMENT USE ONLY <br /> ❑Disapproved Sanitary Perrot Fee °tiudesG(oundwaler ate Issue Issuing g tSigna r N ps) <br /> 4p F]❑Owner Given Initial `/5 charge Fee) Q — <br /> Adverse Determination 1g' - <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SID-6398(It.BSl94) DISTRIBUTION. Original to County.One cu,y To: Satety&Baiidi r�3>Divulon,Owneq PI.o tb r <br />