Laserfiche WebLink
U7-tx_tr L-T <br /> Safety and Buildings Division <br /> SANITARY PERMIT APPLICATION 201 W.Washington Avenue <br /> Visconsin 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 CountyZD <br /> �3, t,Iathan 81/2 x 11 inches in size. 7`IState Sant N,u�ber• See reverse side for instructions for completing this application Personal information you provide may be used for secondary purposes ❑Check revi us application[Privacy Law,s. 15.04(1)(m)]. State PlaerI. APPLI ATI N INFORMATION- PLEASE PRINT ALL INFORMATION �— <br /> Property Owner N e t 7� / LParcel <br /> y Locatione f / 1/a,S /� ,N, R / (or)Property Owner's Mailing Address umber <br /> Ciy,state Zip Code Phone Number Subdivision rCSM tjber <br /> r%jA4 Cr /v/v, 5566 9 (3ao )�8$-gYSrD g earestRoad 2y75� <br /> III YP IL I G: (check one) ❑ State Owned rtpf 4AEo/I <br /> Public 1 or 2 Famil Dwellin -No.of bedrooms � o 3/�c_)r K�r <br /> Ill. BUILDING USE: (if building type is public,check all that apply) <br /> umber(s) <br /> 1 ❑ Apartment/Condo G p�4v <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 /> New 2. eplacement 3, ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an <br /> A) 1 ❑ S stem System -_Tank Only _____________ ExistingSystem -__ ___Exl-----sting ystem <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❑Seepage Trench 22❑In-Ground Pressure 42❑Pit Privy <br /> 13❑Seepage Pit 43❑Vault Privy <br /> 14❑System-In-Fil I <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. Elev7. lnal ation rade <br /> Required(sq.ft.) Proposed(sq.ft.) (Gals/day/sq.ft.) (Min./inch) <br /> 3 O o Feet Feet <br /> 7mp <br /> CapacityjGallons <br /> otal #of site Plastic <br /> in gallons Manufacturer's Name Concrete Con- Steel Fiber-ss App- <br /> INFORMATION New ExistTanksstructed <br /> Tank Tan <br /> olding Tank �� <br /> Siphon Chamber ❑ ❑ ❑ <br /> VIII. RESPONSIBILITY STATEMENT <br /> I,the undersigned,assume responsibility for installation of the onsite sewage system shown on the attached plans. <br /> B <br /> Plumbers Nam :(Prin Plumber's Signature:( Stamps) MP/MPRSWNo.: usiness Phone Number: <br /> CA X <br /> Plumber's Address(Street,City,State,Zip Code): <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> Disapprove Sanitar Permit Fee (IncludesGroundwater ate slue Issuln gent Signature(No Stamps) <br /> ❑ pp surcharge Fee) <br /> Approved ❑Owner Given Initial l��ean <br /> Adverse Determination <br /> X. ONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> DISTRIBUTION: Original to County.One copy To: Safety&Buildings Division,owner.Plumber <br /> SBD-6398(R.4/99) -- — <br />