Laserfiche WebLink
Safety and Buildings Division <br /> =11 <br /> 1LiR SANITARY PERMIT APPLICATION Bureau of Building Water System. <br /> ■ 201 E Washington Ave. <br /> In accord with ILHR 83 05,Wis.Adm.Code P.O.Box 7969 <br /> Madison,W 153707-7969 <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. <br /> • See reverse side for instructions for completing this application State 5anit r Permit Number <br /> The information you provide may be used by other government agency programs ❑Check it rev Bion to previous application <br /> Privacy Law,s. 15.04(1)(m)). <br /> State Plan I.D.Number <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION <br /> Property Owner Name Property Location <br /> 1/4 1/4,S z T N, R E (O(R <br /> Property 0 ner's Mailing Address L N tuber lock Number <br /> r75(05 w�.roov VX. ��r �-% <br /> Cit ,State Zip Code Phone Number Subdivision Name or CSM Number <br /> u evj t4• 5 t IZ• ( <br /> II. TYPE OF BUILDING: (check one) ❑ State Owned ❑ City Neares Road <br /> E] Public 1 or 2 FamilyDwelling- No. of bedrooms 3 Z vod age <br /> wn OF Vuv T <br /> III. BUILDING USE: (If building type is public,check all that apply) Parcel Tax Number(s) <br /> 1 F1 Apartment/Condo czh� -ggas <br /> 2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility <br /> 3 ❑ Campground 7 ❑ Merchandise: Sales/Repairs 11 ❑ Restau ant/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. XReplacement 3. ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an <br /> System System 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 /> 11 V&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 /> RequiS�d (sq- ft.) Proposed(sq.ft.) (Gals/day/sq.ft.) (Mi�./ir ch) Elevation <br /> LISD (��3 O Poll -� Feet Z•3 Feet <br /> TANK Ca aot I <br /> VII. INFORMATION n gallons Total #Of Manufacturer's Name Prefab C n- Fiber- Plastic Aper <br /> New Existin Gallons Tanks Concrete stru ted Steel glass App. <br /> Tanks Tanks �qY <br /> Septic Tank or Holding Tank 1000 V ❑ ❑ ❑ ❑ <br /> Ll fl Pump Tank[Siphon Chamber YL ❑ ❑ ❑ ❑ <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: oStamps) MP/MPRSW No.. Business Phone IN to <br /> Plumber's Address(St lee't,City,SState, pCode): �✓ F �� <br /> L b w 35- G �l 5 <br /> IX. COUNTY/DEPARTM NT SE ONLY <br /> ❑Disapproved Sanitary Permit Fee (1 11.desGmundwatcr ate Issued Issui g ent igna ur ( Stamps) <br /> kApproved ❑Owner Given Initial gP1efi <br /> Adverse Determination <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBI)-639B(R.05199) DISTRIBUTION. Original to Cmim y,One uAy To: S�/erY&RuilJing>Olvuion,Owneq Plwn r <br />