2006/12/11 - SANITARY 19575 - Laserfiche WebLink

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Safety and Buildings Division i ILH i SANITARY PERMIT APPLICATION Bureau of Building Water Systems In accord with ILHR 83.05.Wis.Adm.Cod 201 E.Washington Ave.P.O.Box 7969 Madison,WI 53707-7969 • Attach complete plans(to the county copy only)for the system,on paper not less County than 8 112 x 11 inches in size. I � by s • See reverse side for instructiclos for completing this application State Sanitary Fermi be, The information you provide maybe usedb other overnmenta enc programs Y P Y Y 9 agency P 9 E]Check if revision to previou application IPrivacy Laws. 15.04(1)(m))_ State Plan l.D.Number I. APPLICATION INFORMA ON - PLEASE PRINT ALL INF RMATI N Z� Property Owner Name Property Location Go✓ Z ©s Z 1/4 1/4,S 3 T Yo ,N, R/y E(or)�g Pr6perty0 ner's Mailing Address Lot NumbE r Block Number Dk- C J _ Cit ,State ZIP CodePhone Number Subdivisio Name or CSM Number r W� Yov ( > 3393 C lcft✓ecot-de d P/Ct I. TYPE OF BUILDING: (chee one) ❑ State Owned ❑ it� Nearest Road Vil aqe 1� Public 1 or 2 FamilyDwelling-No.of bedrooms �_ Town o S� 7T c L , III. BUILDING USE: (If buddiniftpe is public,check all that apply) Parcel Tax umbers) 1 ❑ Apartment/Condo ', 28_ 413q-05 0l0 2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility 3 ❑ Campground 7 ❑ Merchandise: Sales/Repairs 11 ❑ Restaurant/Bar/Dining 4 ❑ Church/School I8 ❑ Mobile Home Park 12 E] Service Station/Car Wash 5 E] Hotel/Motel �9 ❑ Office/Factory 13 ❑ Other: specify IV. TYPE OF PERMIT: (Check my one box on line A. Check box on line B, if applicable) A) 1. New 2 ❑ Relacement 3. ❑ Replacementof q ❑ Reconnectionof S ❑ Repair of an System Sys em -- - Tank Only Existing System- -- Existing System --------- ------ B) ❑ A Sanitary Permit wa' previously issued. Permit Number Date Issued V. TYPE OF SYSTEM: (Check my one) Non-Pressurized Distribution i Pressurized Distribution E perimental Other 11 [Seepage Bed 21 El Mound 3 ❑Specify Type 41 C3 Holding Tank 12(�Seepage Trench 22❑In-Ground Pressure 42❑Pit Privy 13❑Seepage Pit 43 El Vault Privy 14❑System-In-Fill VI. ABSORPTION SYSTEM IF FORMATION: 1.Gallons Per Day 2. Absgr .Area 3. Absorp.Area 4. Loading Rate S. Perc. Rate 6. System Elev. 7. Final Grade Require (sq. ft.) Proposed(sq.ft.) (Gals/day/sq.ft. (Min./inch) Elevation 3o o y� vow , 6 — �Y- 9 Feet 97, 3 Feet C4 aclt VII. TANK in Ilons Total #of Prefab. Site Fiber- Exper INFORMATION Gallons Tanks Manufacturer's Name concrete con- Steel ass Plastic Ap New E Tanks structed 9 pp Tank' Tanks Septic Tank or Holding Tank 75- Z:5-0 ® ❑ 11 ❑ El ❑ L ift Pum p Ta nk/S iphon Cham ber IEl El E] El El El VIII. RESPONSIBILITY STATEMENT I,the undersigned,assume res acinsibiIity for installation of the onsite sewage system shown on the attached plans. Plumber's Name:(Print) Plumber's Signature:(No Stamps) MP/ PRSW No.: Business Phone Number. 6c-11¢o% a �s�a/ G✓�.l �� yy=7 �� Plumber's Address(Street,City,State,Zip ode): ,90 w Y S/�—e 6__-1 �7 IX. COUNTY/ DEPARTMEN USE ONLY ❑Disapproved Sanitary Permit Fee lindude,Gmundwaier ate IssuedIssuing en ignature( amps) 1,�Y4pproved ❑Owner Given I itial / OU su,,h,n9eFee) y �y� Adverse Deter ination l.� /2 / X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: SRO R.0SI94) DISTRIBUTION: Original to Caunry,One copy To. safety BBu dimy Division.Owner,Plumber