Laserfiche WebLink
Safety and Buildings Divisiont <br /> VisConsin SANITARY PERMIT APPLICATION 201 W.Washington Avenue <br /> P O Box 7302 <br /> Department of Commerce In accord with Comm 83.05,Wis.Adm.Code Madison,WI 53707-7302 <br /> • Attach complete plans(to the county copy only)for the system,on paper not less Co ty / <br /> than 81/2 x 11 inches in size. y <br /> • See reverse side for instructions for completing this application State sanitary Permit NbInber <br /> Personal information you provide may be used for secondary purposes )n to pr <br /> (Privacy Law,s. 15.04(1)(m)]. ❑Check it revisioevi us application <br /> State Plan I.D.Number <br /> I. APPLICATION INFORMATION- PLEASE PRINT ALL INFORMATION <br /> P ertyOwngrNam pro ert Lo ation <br /> iC �dtdl Vie( SEt/aIt/ 1/4,53 T ,N, R &4orW <br /> Pro erty Owner's Mailing ddress Lot Number Block Number <br /> c/SOG `B/' ne[1 4414e- <br /> City State Zip Code Phone Number Subdivision Name or CSM Number � <br /> W ' S 7 (7/S)&(7-Z003 q <br /> II. TYPE OF BUILDING: (check one) ❑ State Owned El it Nearest Road I <br /> El Public 1 or 2 FamilyDwelling-No.of bedrooms 5[rowan OF Meevt oy\ SH-wtfe gj -7 (!--) <br /> III. BUILDING USE: (If building type is public,check all that apply) Parcel TaxNumber(s) <br /> 1 ❑ Apartment/Condo 0 1 $ 333 OS q0C) <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. 0 New 2. ❑ Replacement 1 ❑ Replacement of 4_ ❑ Reconnection of S. ❑ 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 0Seepage 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. GallonsPer Day 2. Absorp.Area 3. Absorp.Area 4. Loading Rate 5. Perc. Rate 6. System Elev. 7. Final Grade <br /> 3 OO Required(sq.ft.) Proposed(sq.ft.) (Gals/day/sq.ft.) (Min./inch) c Elevvation <br /> 4Z I '43Z- G Z Feet FS_ Feet <br /> VII. TANK Capacity <br /> INFORMATION in gallons Total #of Manufacturer's Name Prefab. Site Fiber- Exper <br /> New Existin Gallons Tanks Concrete Con- Steel glass Plastic App <br /> Tanks Tank strutted <br /> =Tanor Holding Tank -7 <br /> Lift Pump Tank/Siphon Chamber ❑ 1:1 El Q <br /> VIII. RESPONSIBILITY STATEMENT <br /> 1,the undersigned,assume responsibiI y for installation of the onsite sewage system shown on the attached plans. <br /> Plumber's Name:( rl ) Plu tier's Signatu e:( Stamps) MP/MPRSW No.: Business Phone Number: <br /> ve(S rfPr I' 2zrZz 7�r 6- 08- <br /> Plumber's Address(Street,City, tate,Zip Code): <br /> ff <br /> IX COUNTY/DEPARTMENT USE ONLY <br /> ❑Disapproved Sanitary Permit Fee (inciudesGroundwater ate Issued Issuing Agent Signature(No Stamps) <br /> Approved [-]Owner Given Initial I�5 Surcharge Fee) <br /> Adverse Determination , <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(R.4/99) DISTRIBUTION: Original to County.One copy To: Safety&Buildings Division,Owner,Plumber <br />