Laserfiche WebLink
Vlili:6nsiSANITARY PERMIT APPLICATION Safety and Buildings Division <br /> n 201 E.Washington Ave. <br /> Department of Commerce 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 County <br /> than 81/2 x 11 inches in size. &e r2 e 7 <br /> • See reverse side for instructions for completing this application State Sanitary Per/milt Numbeear, <br /> The information you provide maybe used by other government agency programs 3% (f/O-Z <br /> [Privacy Law,s. 15.04(1)(m)). - ❑Check it revision t ious application <br /> 1. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION State Plan I.D.Number <br /> Prop rtyOwner Name /C Popert Location !� <br /> Prop <br /> Or CID ec�L s 1/4 1/a,S —I T 3� r N, R /S� E(Or)® <br /> Property wne 's Mailing Addr ss Lot Number^ Block Number <br /> ✓' Sit/ <br /> Cit State Zip Code Phone Number Subdivision Name or CSM Number <br /> MX S'.f oq-0 ( > e-Sm V 4 !�r 1 <br /> if. TYPE F B IL ING: (check one) ❑ State Owned ❑ it� L Nearest Road <br /> Public 1 or 2 FamilyDwelling- No.of bedrooms ❑ Vil age / G )/ <br /> _ Town OF /¢ rFO�/Gt'f�, r <br /> -70 <br /> III. BUILDING USE: (If building type is public,check all that apply) Parcel Tax Number(s) <br /> 1 ❑ Apartment/Condo 0/+ ddW4 O4 30o <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 EI-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 5 stem 2- (W Replacement 3. E] Replacement of 4_ E] Reconnection of 5. ❑ Repair of an <br /> _______y _____ y 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 /> 112 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 /> Require (sq. ft.) Prop (sq. ft.) (Gals/day/sq.ft.) (Minim/inch) — Elevation <br /> 8 '� �' 7 Feet 9�. Feet <br /> VII. TANK Capacity <br /> INFORMATION in gallons Total #of Prefab. Site Fiber- Ex <br /> New Existing Gallons Tanks Manufacturer s Name Concrete Con- Steel glass Plastic App. <br /> Tanks Tanks structed <br /> Septic Tank or Holding Tank /000/dQQ 7j W ® ❑ El ❑ <br /> Lift Pump Tank/Siphon Chamber Q ❑ El ElVIII. RESPONSIBILITY STATEMENT <br /> I,the undersigned,assume responsibility for installation of the onsite sewage system shown on the attached plans. <br /> Plumber's Name: Plumber's Signature (No amps) MP/MPRSWNo-: Business Phone <br /> �Number: _ <br /> Q I <br /> FA umber's Ac dress S reet,City,State,Zip Code) <br /> z7 -1-1690 fiyj %- U 1. 54913 <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑Disapproved Sanitaary Permit (includes Groundwater ate ssue Issuing Agent gnatur (No t ps) <br /> proved ❑Owner Given Initialrcnarge Fee) <br /> Adverse Determination <br /> �ay�y f <br /> X CONDITIONS OF APV <br /> AL/REASONS FOR DISAPPROVAL: <br /> SBO-6398(R.11196) DISTRIBUTION: Original to county,One copy To: Safety 8 Buildings Division,Owner,Plumber <br />