Laserfiche WebLink
4� �Z'vv Safety and Buildings Division <br /> `�SCO►15%D SANITARY PERMIT APPLICATION 201 W.Washington Avenue <br /> In accord with ILHR 83-05,Wis.Adm.Code P O Box 7302 <br /> Department of Commerce Madison,WI 53707-7302 <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. <br /> • See reverse side for instructions for completing this application St to Sanitary Permit Number <br /> - <br /> Personal information you provide may be used for secondary purposes � �9 51 <br /> ❑Check if revision to pre ious application <br /> (Privacy Law,s. 15.04(1)(m)]. <br /> State Plan I.D.Number <br /> I. APPLICATION INFORMATION- PLEASE PRINT ALL INF RMATION <br /> Property Owner Name Prope�rt,y Locat n <br /> LAgizv PC-1-W4CsoV,41M S iQ T40 ,N,R $ E(or W <br /> Propert wne 7 Mailing Address Lot Number a Block Number <br /> City,StateZip Code P one Number Subdivision Name or CSM Number <br /> M ( iv <br /> Ill. P BUILDING: (check one) ❑ State Owned ❑ City Nearest Road v �►O <br /> ❑ Village ✓/►�"� nn <br /> Public 1 or 2 FamilyDwelling-No.of bedrooms Town OF 1W <br /> III. BUILDING USE: (If building type is public,check all that apply) Parcel TaxNumber(s) <br /> 1 C] Apartment/Condo o!1--2 8— TZZ// 0 7 40 <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 /> S ❑ 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. ;&Replacement 3, ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an <br /> ------System ----_---SystemTank-Only---------------Existing System----------Existing 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 CJ 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. Perc. Rate 6. System Elev. 7. Final Grade <br /> Required(sq_ft.) Proposed(sq.ft.) (Gals/day/sq.ft.) (Min./inch) Qlevation <br /> 300 29 , 1 1. Feet Feet <br /> TANK Capact <br /> VII. INFORMATION in allons Total #of Manufacturer's Name Prefab con steel Fiber- Plastic Exper. <br /> New Existin Gallons Tanks concrete structed glass App. <br /> Tank Tanks <br /> Septic Tank or Holding Tank 7,co —_ Q G 1_ ❑ ❑ ❑ ❑ <br /> Lift Pump Tank/Siphon Chamber ❑ ❑ ❑ 1 ❑ ❑ <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 mps) MP/MPRSW No-: Business Phone Number: <br /> tct�gRp N f .3 <br /> PI mber's Address(Street,City,State,Zi Code). <br /> wX 3S BsT 1J1•,54�93 <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑Disapproved Sanitary Permit (Includes Groundwater ate IssuedIssuing ent ignat a(No S s) <br /> proved ❑Owner Given Initial ��V_, Surcharge Fee) <br /> `J Adverse Determination <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(R.11/97) DISTRIBUTION: Original to County.One copy To: Safety&Buildings Division,Owner,Plumber <br /> t, <br />