Laserfiche WebLink
Safety and Buildings Division <br /> ` SCIDDS%/1 SANITARY PERMIT APPLICATION 201 E.Washington Ave. <br /> In accord with ILHR 83.05,Wis.Adm.Code P.O.Box 7969 <br /> Department of Commerce Madison,WI 53707-7969 <br /> • Attach complete plans(to the county copy only)for the system,on paper not less Count <br /> than 8 12 x 11 inches in size. uglg,T �3 6 <br /> • See reverse side for instructions for completing this application State Sanitary Permit Number Nuum[bSer o^7� <br /> The information you provide may be used by other government agency programs ❑Check it revision 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 Ower Name Property Location <br /> HAACXva va,S ""-T T -W ,N, R 1( E(or) <br /> Property OLWer's Mail ing ddress + Lot Number Block Number <br /> Z4 N4 W <br /> Cit ,states `,`�wJ Zip Code Pone Number Subdivision Name or CSM Number <br /> MtA. l2 ( > w <br /> II. TYPE F B ING: (check one) C] State Owned 0 City Nearest Road <br /> Village <br /> Public 1 or 2 Family Dwelling-No.of bedrooms iTown OF aw(wil , <br /> RD- <br /> Ill. BUILDING USE: (If building type is public,check all that apply) Parcel TaxNumber(s) ,1 <br /> 1 E] Apartment/Condo ce 7— I <br /> 2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility <br /> 3 ❑ Campground 7 ❑ Merchandise: Sales/Repairs 11 0 Restaurant/Bar/Dining <br /> 4 ❑ Church/School 8 ❑ Mobile Home Park 12 ❑ Service Station/Car Wash <br /> S ❑ 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. E] Replacement of 4_ E) Reconnection of 5_ ❑ Repair of an <br /> System System Tank Only Existing System Existing System <br /> ----------------------------------------------------------------------------------------------- <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 M'Seepage Bed 21 [-]Mound 30❑Specify Type 41 ❑Holding Tank <br /> 1 f 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. 17. Final Grade <br /> Req fired(sq.ft.) Pro osed(sq.ft.) (Gals/daylsq.ft.) (Min./inch) w // Elevation <br /> 4-9;l , �� 9A .t0 Feet Feet <br /> Ca acct . <br /> VII. INFORMATION in gallons Total #of Manufacturer's Name Prefab. Site Con- steel Fiber- plastic Exper. <br /> New Existing Gallons Tanks Concrete structed glass App. <br /> Tanks Tanks <br /> Septic Tank or Holding Tank ❑ ❑ ❑ ❑ ❑' <br /> Lift Pump Tank/Siphon Chamber ❑ , ❑ ❑ 1 ❑ ❑ <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: o ps) MP/MPRSWNo.: BuinessPhoneNumber: <br /> 1cO�r2v rIS u 6�+kd{ 25851 - S <br /> Plu ber's Ac dress(street,City,itate,Zip Code): <br /> w 3 t. S13 <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑Disapproved Sanitary Permit Fee II"cludesinroundwoter Date Issued Issuing en ignat re(14% amps) <br /> A roved E]Owner Given Initial �� &Z!u rgeFee) <br /> Adverse Determination lJ <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> DISTRIBUTION: Original to County.One copy To: Safety&Buildings Division,Owner,plumber <br />