Laserfiche WebLink
PlGew <br /> Safety and Buildings Division <br /> sconsin SANITARY PERMIT APPLICATION 201 W.Washington Avenue <br /> P O Box 7302 <br /> Depanment 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 County ay _ <br /> than 8112 x 11 inches in size. Va r n ti 1615 <br /> • See reverse side for instructions for completing this application State S�lta�e2 it u�m er <br /> Personal information you provide may be used for secondary purposes ❑Check if revision to previous application <br /> [Privacy Law,s. 15.04(1)(m)]. State Plan I.D.Number U� <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INF RMATI N <br /> Property O er Nam Property Loc tion <br /> `vurl/a wr�ila,S �.S—T ti-io ,N, R 16 E(or)( <br /> Property Owner's Mailing Address Lot Number Block Number <br /> I <br /> City,State Zip Code Ph ne Number Subdivision Name or CSM Number <br /> ( S 1-42-319 8 /ONcrc <br /> 11. TYPE B LDING: (check one) ❑ State Owned City /_ Nearest Road Wel Public 1 or 2 FamilyDwelling-No.of bedrooms O Town OF o/¢/c%Ih Bu ¢ We <br /> III. BUILDING USE: (If building type is public,check all that apply) Parcel TaxNumber(s) <br /> 1 ❑ Apartment/Condo D " 4341.5 — 6 0 <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. X New 2. ❑ Replacement 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 ❑Seepage Bed 21 ❑Mound 30❑Specify Type 41 ❑Holding Tank <br /> 12 JR 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 /> 4S'O Required(sq.ft.) Proposed(sq.ft.) (GaWday/sq.ft.) (Min./inch) Elevation <br /> 960 ��� Jr- 9-s y Feet '7(7,47 Feet <br /> VII. TANK Capacity <br /> INFORMATION in gallons Total #of Manufacturer's Name Prefab. Con- Fiber- Plastic Exper <br /> New Existin Gallons Tanks concrete strutted steel glass App. <br /> Tanks Tanks <br /> Septic Tank or Holding Tank /4900 /QOQ ® El ❑ ❑ ❑ ❑ <br /> Llft Pump Tank/Siphon Chamber (add Al ❑ ❑ ❑ 1 ❑ Ej <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 Signa re• Stamps) MP/MPRSWNo.: Business Phone Number: <br /> n <br /> ►c»��72p oyya�s z2S8�1 <br /> P mber's Address(Street,City,State,Zip Code). <br /> w U/ — <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑Disapproved Sanitary Permit'FudesGroundwater Date Issued suing AWSign <br /> r N ps) <br /> roved ncharge Fee) <br /> *P'� <br /> ❑Owner Given Initial < <br /> Adverse Determination �✓�/ CNI <br /> X. CONDITIONS OF APPRppV L/RE ONS FOR DISAPPROVAL: <br /> Tn54 6 eAe4- Ill 1 �-OL <br /> SBD-6398(R.4/99) DISTRIBUTION: Original to County,One copy To: Safety&Buildings Division,Owner,Plumber <br />