Laserfiche WebLink
0� <br /> V6onshi <br /> Safety and Buildings Division <br /> SANITARY PERMIT APPLICATION- Po BWashington Ave. <br /> Department of commerce In accord with[LHR 83.05,Wis.Adm.Code Madison,WI 53707.7969 <br /> • Attach complete plans(to the county copy only)for the system,on paper not less County <br /> than 8 112 x 11 inches in size. "-u �a :�3 <br /> • See reverse side for instructions for completing this application State Sanitary Permit Number <br /> The information you provide may be used by other government agency programs ❑check it revision to previous appl ation <br /> [Privacy Law,s. 15.04(1)(m)]. State Plan I.D.Number <br /> I. APPLICATION INFORMATION- PLEASE PRINT ALL INFORMATION <br /> Property Owner Name Property Location <br /> Afl- o/( Zee 1/4 1/4,S Tap ,N, R 111W E(or W <br /> Propert Owner's Wiling Address Lot Number Block Number <br /> ,� � Qom . � <br /> City,St to Zip Code Phone Number Subdivision me or CSM Number <br /> I1. TYPE OFBUILDING: (check one) ❑ State Ownedo v is a �,/n� Nearest Road J <br /> Public or 2 FamilyDwelling- No.of bedrooms Town OF J% C,_ <br /> III. BUILDING USE: (If building type is public,check all that apply) Parcel Tax Number(s) J <br /> 1 ❑ Apartment/Condo 0 n U ( � 3 6c C) <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 /> System _ystem - Tank Only _ Existing System----------Existing System <br /> B) ASanitary Permit was previously issued. Permit Number a� gg � Date Issued 10_3r7 <br /> V. TYPE OF SYSTEM: (Check only one) <br /> Non-Pressurized Distribution Pressurized Distribution Experimental Other <br /> 11 JaSeepage 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.Area3. Absorp.Area 4. Loading Rate S. Perc. Rate 6. System Elev. 7. Final Grade <br /> �+1 — Required(sq.ft.) Pro osed(sq.ft.) (Gals/d /sq.ft.) (Min./inch) a Elevation <br /> Feet f�, Feet <br /> Capacct <br /> VII. INFORMATION in allons Total #of Manufacturer's Name Prefab. site Con- steel Fiber- Plastic Exper- <br /> New Existin Gallons Tanks concrete strutted glass App. <br /> Tanks Tanks <br /> Septic Tank or Holding Tank I Cry ©Z El El 1:1 El 1:1Lift Pump Tank/Siphon Chamber �_61 ❑ ❑ ❑ I ❑ ❑ ❑ <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 Namq):(Print) I Plumber's Signat re:(N am s) MP/MPRSW No.: Business Phone Number: <br /> Plumber's Ar dress(Street,City,State,Zip Code): <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑Disapproved Sanitary Permit Fee (IndudesGroundwater ate IssuedIssuing A ent Si nature( S amps) <br /> pproved ❑Owner Given Initial �ur<hargeFee) O <br /> Adverse Determination 64 � <br /> X. CONDITIONS OF APPROVAL/RE.ASONS F DISAPPROVAL: <br /> SBD-6398(R.11/96) DISTRIBUTION: Original to County,One copy To: Safety&Buildings Division,Owner,Plumber <br /> I __ <br />