Laserfiche WebLink
Safety and Buildings Division <br /> etil�iin 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,WI 53707-7969 <br /> • Attach complete plans(to the county copy only)for the system,on paper not less Cou orgz <br /> than 8 1/2 x 11 inches in size. <br /> • See reverse side for instructions for completing this application State Sanitary Permit Numb r <br /> o/� r� t <br /> The information you provide may be used by other government agency programs ❑Check it revision to previo s application <br /> (Privacy Law,s. 15.04(1)(m)]. State Plan I.D.NumberA / <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION N <br /> Prop Owner Nam Property Location �7 <br /> 1/4 1/4,5 /0 T 3d ,N, R %S E(or)gi t}. <br /> Property wrier' Mailin Addr s Lot Number ` <br /> p Y9 9 3 Aze � � c5 > Block Number <br /> Ci�State /� Zip Cod TPhone Numbef Subdivision Name or CSM Number <br /> 11. TYPE OF BUILDING: (check one) ❑ State Ownedt� N crest Road <br /> Vil age LQI��/ /� ���1/ �� <br /> Public 1 or 2 FamilywellingD -No.of bedrooms Town of <br /> III. BUILDING USE: (If building type is public,check all that apply) Parcel TaxNumber(s) <br /> 1 ❑ Apartment/Condo <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. W Replacement 3. [:] Replacement of 4. E] Reconnection of S. 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❑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. Pert. Rate 6. System Elev- 7. Final Grade <br /> 7/1�y Required sq. ft.) Proposed(sq. ft.) (Gals/da /sq.ft.) (Min./inch) EI rvvat`ion <br /> 6(co 7/��,1 Feet7,11 CP Feet <br /> Capcit <br /> VII. TANK in allons Total #of Prefab Site Fiber- Exper <br /> INFORMATION Gallons Tanks Manufacturers Name Concrete Con- Steel Plastic p <br /> New Existin strutted glass App. <br /> Tanks Tanks <br /> Septic Tank or Holding Tank �VQ2 1 50 1-1 El El El <br /> I.ift Pump Tank/Siphon Chamber ��jw 1 5! ) ❑ El E 0 <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) Plumber's Signature:(No Stamps) MP/MPRSW No.: Business Phone Number: <br /> Plum is Addres Street,City,Sta ,Zip Code) <br /> IX. COUNTY/ DEPARTMENT USE ONLY <br /> ❑DisapprovedSanitary Permit Fee (includescroundwater ate slue Issuing Agent ignature(N S mps) <br /> ,KA roved °«nargelee) <br /> PP []Owner Given Initial GQIF <br /> Adverse Determination ® 7/310/4 <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBO-6398(ll.05/94) DISTRIBUTION: original to County.One ropy To: Safety 8 fluildinys Division,owner,Plumber <br />