Laserfiche WebLink
_ N C' <br /> Safety and Buildings Division <br /> WET Bureau Bureau of Building Water Systems <br /> v■�■>.■>. SANITARY PERMIT APPLICATION 201E Washington Ave <br /> In accord with ILHR 83 05,Wis.Adm.Code P.O.Box 7969 <br /> Madison,r <br /> 153707-7969 <br /> • Attach complete plans(to the county copy only)for the system,on papernot less County 9s9y <br /> than 8lrz x 11 inches in size. �LtPh� <br /> • See reverse side for instructions for completing this application State SanitaryPermit <br /> Numbb/Jeerr <br /> The information you provide may be used by other government agency programs ❑check if r cion topreviiouus application Sj <br /> (Privacy Law,s. 15.04(1)(m)I. State Plan 1.D.Num her /�r <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION �G ��'0 7 8 <br /> Pro /Aerty Owner Name 1Property Locatiio0Sn <br /> , Vy1 <br /> L) ;C/ r,4 r^ 7s.is .5 S i v T N, R /'-,5--EE(Or) <br /> Property Owner's Malting Address Lot Number Block Number <br /> City,State _ ip Code Phone Number Subdivision Name or CSM Number <br /> II. TYPE OF BUILDING: (check one) ❑ State Owned ❑ Cit Nearest Road] <br /> ❑ village �.A�' 6 //'t/ ' �',^ig.J bt/`/' ;47411c)Public 1 or 2 Family Dwelling- No. of bedrooms Town F <br /> III. BUILDING USE: (If buildingtype is public,check allthatapply) Parcel Tai Number(s) /I/ ,_ )a/Q- 316 <br /> 1 ❑ Apartment/Condo c:;=w "'�� — _4-0� <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. ® New 2. ❑ Replacement 3. ❑ Replacement of q ❑ Reconnection of 5- ❑ Repair of an <br /> System System Tank Only Existing System _E_xis_ting_System <br /> B) ❑ A Sanitary Permit was previously issued- Permit Number i Date Issued <br /> V. TYPE OF SYSTEM: (Check only one) <br /> NonPressurizedDistribution Pressurized Distribution Experimental Other <br /> 11 ❑Seepage Bed 21 [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 /> Required(sq. ft.) Proposed(sq.ft.) (Gals/day/sq. fit.) (Min./inch) Elevatiofl <br /> ..G'S D ?5 1 /. — �� <br /> 1. Gallons Per D��_] .3 Feet /6w( Feet <br /> Capacit <br /> VII. TANK n allons To #Of Prefab Site Fiber-ass Plastic Aper <br /> INFORMATION Gallons Tanks Manu Concrete Name Concrete con- steel <br /> New Existingstrutted <br /> Tanks Tanks <br /> Septic Tank or Holding Tank 75? ❑ ❑ El 1:1 11Lift Pump Tank/Siphon Chamber - 'z 1 bc1 2- ❑ ❑ ❑ ❑ ❑ <br /> VIII. RESPONSIBILITY STATEMENT <br /> I,the undersigned, assume responsibility for installation of the onsite selvage system shown on the attached plans. <br /> Plumber's Name:(Print) / Plum bet's SignatureM:(NoS mps) ,j /MPRSWNcr : Business Phone Number: <br /> 4 p <br /> oi'ppe_ N��I n�/1'i ck-rs- moi, ✓/h / .. �`�` �..�q <br /> Plulnrs Address(Street,City,State,Zip Code). <br /> IX. COUNTY/ DEPARTMENT USE ONLY <br /> El Disapproved Sanitary Permit Fee include,Groundwater Date :suecl Issuing Agent Si nature( 5 mps) <br /> Approved A jordo"ele') / 7 !7 <br /> pp ❑Owner Given Initial L/ 2 <br /> Adverse Determination <br /> X. CONDITIONS OF APPROVAL/ REASONS FOR DISAPPROVAL:. <br /> SHID 398(R.05194) DISTRIBUTION'. Original m Counl y.one<oPV to: SAA'9,14 T ing,Mv....n,Owner,Plumter <br />