Laserfiche WebLink
Safety and Buildings Division <br /> Bureau of Building Water System, <br /> ��■...,ra SANITARY PERMIT APPLICATION!!l��� /� 201 E.Washington Ave. <br /> 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 8 1/2 x 11 inches in size. <br /> • See reverse side for instructions for completing this application State Sanitary Peri /�mb�r <br /> The information you provide may be used by other government agency programs ❑CheuV rrevTsiorfrd`,e'v'Ibua•'appIicaIinn <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 C,+ Property Location <br /> �N CL.ENDEN N 1/4 1/4,S 21 T 41 N, R � E(o W <br /> Property Owner's Mailing Address Lot Number Blgek-�ygalter <br /> K 5-T- L- 3 <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number i r <br /> t4j , ( ) 3 P 4qq VOL- 99 F. s_ z$ <br /> II. TYPE OFBUILDING: (check one) ❑ State Owned ❑ city Nearest Road <br /> C] Village e+T <br /> Public 1 or 2 FamilyDwelling- No. of bedrooms Town OF SLJI5S J1 - <br /> HI. BUILDING USE: (If buildingtype ispublic,check allthatapply) Parcel TaxNumber(s) <br /> 1 ❑ Apartment/Condo 03Z. $3?J 0I too <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_ E] Replacement 3. E] Replacementof 4_ ❑ Reconnection of 5. E] 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 /> NonPressurizedDistribution Pressurized Distribution Experimental Other <br /> 11 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 /> Reguir d (sq-ft.) Pro o ed(sq.ft.) (Gals/day/sq. ft.) (Min./inch) Elevation <br /> IND (p ?j 8 '~ 9S.9 Feet 99 .1 Feet <br /> Capact <br /> VII N ORMATION in gallons Total #of Manufacturer's Name Prefab Con Fiber- Plastic Exper <br /> Gallons Tanks Concrete Steel glass App. <br /> New Existin strutted <br /> T//a�nnk�/k�s Tanks / <br /> Septic Tank or Holding Tank IOM 000 —L+ % ❑ ❑ ❑ ❑ ❑ <br /> Lift Pump Tank/Siphon Chamber I 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 Name:(Print) Plumber's�+ Signature: No mps) MP/MPRSW No.: Business Phone Number: <br /> v 3q2.6 1s- - -5 <br /> PI mber's Address(Street,Citytate,Zip Code): <br /> 2-11GoV -':W WQS�T g W1 , <br /> IX. COUNTY/ DEPART NT USE ONLY <br /> E]Disapproved Sanitary Permit Fee (Indude5C,roundwater atelssue Issuing Agen ignature amps) <br /> roved SLr`harge Fee) <br /> pp ❑Owner Given Initial �� <br /> Adverse Determination (1� <br /> X. CONDITIONS OF APPROVAL/REASONS FOR IS PPROVAL: <br /> SBD6398(R.BS194) DISTRIBUTION: Original to Cc000,One co,,To: Sufuty&Building,Diveion,owner,Plumber <br />