Laserfiche WebLink
�/� SANITARY PERMIT APPLICATION 1 W.Washington <br /> Buildings Division <br /> 201 W.Washington Avenue <br /> _�consin In accord with ILHR 83.05,Wis.Adm Code P O Box 7302 <br /> ,,,-Oepartment of Commerce Madison,WI53707-7302 <br /> • Attach complete plans(to the county copy only)for the system,on paper not less Count n <br /> than 8 vi x 11 inches in size. 7 <br /> • See reverse side for instructions for completing this application State Sanitary Permit3mber 1 4 <br /> Personal information you provide may be used for secondary purposes ❑check it�sl t©evious application <br /> [Privacy Law,s. 15.04(1)(m)]. State Plan I.D.Number <br /> I. APPLICATION INFORMATION- PLEASE PRINT ALL INF RMATION I <br /> Prop e Own r Name t Property Location <br /> / 1/4 v4,S l T yCi ,N, R /5't'(or) <br /> !'d C e- <br /> Pro erty Owner's Mailing Addresst G,�+ 2 Block Number <br /> City,State Zip Code I Phone Number Subdivision Name or CSM Number <br /> ve.r reeA AIM &,6y0_05-- voy >, 6 3�5 <br /> II. F BUILDING: (check one) ❑ State Owned 0 1-ity Nearest Road <br /> d a --(('- <br /> Public 1 or 2 FamilyDwelling-No.of bedrooms ❑ TVown e OF ct41 'C-ac's e <br /> III. BUILDING USE: (If building type is public,check all that apply) Parcel TaxNumber(s) <br /> 1 ❑ Apartment/Condo p/`;7 <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. ❑ Replacement 3, ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an <br /> _ _ _ TankOnlY m Existing <br /> ________ <br /> B) <br /> ❑ 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 /> 12Meepage Trench 22❑In-Ground Pressure 42❑Pit Privy <br /> 13❑Seepage Pit f� L 43❑Vault Privy <br /> 14❑'System-In-Fill <br /> VI. ABSORPTION SYSTEM INFORMATION: <br /> 1.Gallons Per Day 2. Absorp.Area 13. Absorp.Area 4. Loading Rate 5.Perc. Rate 6. System Elev. 7. Fina[ Grade <br /> Required(sq.ft.) Proposed(sq.ft.) (Gals/day/sq.ft.) (Min./inch) c� Elevation <br /> I j 1 S 4, 3 -5- 7p n / Feet 71S Feet <br /> VII. TANK Capacity site <br /> in gallons Total #of Manufacturer's Name Prefab. Con_ Steel Fiber- plastic Exper <br /> INFORMATION Gallons Tanks Concrete glass App. <br /> New Existin structed <br /> Tanks I Tanksl <br /> Septic Tank or Holding Tank le190 � I E <br /> Lift Pump Tank/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 /> Plumper Is Name:(Print) Plumbers Signature: No Stamps) MP/MPRSW No.: Business Phone Number: <br /> Plumb is Address(Street,City,Stat,Zip Code): <br /> .lax <br /> IX. COUNTY/ DEPARTMENT USE ONLY <br /> ❑Disapproved Sanitary Permit Fee (Includes Groundwater ate slue Issuing ge Sig u ps) <br /> roved D charge fee) <br /> pp []Owner Given Initial � <br /> Adverse Determination <br /> X. CONDITIONS OF APPROVAL/REASONS FOR APPROVAL: <br /> SBD-6398(R.11/97) DISTRIBUTION: Original to County.One copy To:Safety 8 Buildings Division,Owner,Plumber <br />