Laserfiche WebLink
Safety and Buildings Division <br /> SANITARY PERMIT APPLICATION Bureau of Building Water Systems <br /> 201 E.Washington Ave. <br /> In accord with ILHR 83.05,Wis.Adm-Code P.0-Box 7969 <br /> Madison,WI 53707-7969 <br /> • Attach complete plans(to the county copy only)for the system,on paper not less CountYQ <br /> than 8112 x 11 inches in size. L� kYYte�� ao� Q <br /> • See reverse side for instructions for completing this application State Sanitr rmi N ber s <br /> The information you provide may be used by other government agency programs E]Chec I revisionntOto prewou5 plication <br /> [Privacy Law,s. 15.04 0)(m)I. State Plan I.D.Number <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION <br /> Property Owner Name �p Property Location <br /> D i e 54, r f� W 1/4s& 1/4,5 ((o T,Z N, RI I E-(,oro <br /> Property Owner's Mailing Addre s ,n Lot Number Block Number <br /> L <br /> City,State Zip Code Phone-Number Subdivision Name or CSM Number <br /> 5 O ( 7/S) &3-3373 <br /> 11. TYPE OF ILDING: (check one) ❑ State Owned ❑ It Nearest Road <br /> Z ❑ Village /� p <br /> Public 1 ort Famil Dwellin - No.of bedrooms L Town oFGr t by 5 r k FQ. —70 <br /> III. BUILDING USE: (if buildingtype ispublic,check allthatapply) Parcel TaxNumber(s) c..j <br /> 1 ❑ Apartment/Condo /o `ter <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. Dd 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";g6eepage 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 S. Perc. Rate 6. System Elev- 7. Final Grade <br /> Required (sq. ft-) Proposed(sq-ft.) (Gals/day/sq-ft.) (Min./inch) // Elevation <br /> l(3 `f , 7 p/,O Feet 97. O Feet <br /> ap <br /> VII. TANK C <br /> in alloant s Total #of Prefab. Site Fiber- Exper <br /> INFORMATION g Gallons Tanks Manufacturer's Name Concrete con- Steel glass Plastic App <br /> New Existin svucted <br /> Tanks Tanks <br /> : e�pticTan or Holding Tank ;5-or Ig ❑ ❑ ❑ ❑ ❑ <br /> Ll"umpTank/Siphon Chamber ❑ ❑ ❑ ❑ ❑ ❑ <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:( PI ber's Signatur Stamps) MP/MPRSW No.: Business Phone Number: <br /> Print <br /> ,e [ o-e ga S- 7/ pro- F6DE <br /> Plumber's Address(Street, l� <br /> tyState,Zip Co ): _tl� t� ` <br /> IX. COUNTY/DEPART'MJTF1 NT USE ONLY <br /> ❑Disapproved Sanitary Permit Fee (Includes Groundwater ate Issue Issuing Age t S natur (No S m ) <br /> A roved i urchargefee) <br /> pp ❑Owner Given Initial /�� . O� <br /> Adverse Determination <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SMD-6398(R.OV94) DISTRIBUTION. Original to County,One copy TO: Safety B Build Ings Dim;ion,Owner,Plumber <br />