Laserfiche WebLink
Safety and Buildings Division <br /> SANITARY PERMIT APPLICATION Bureau of Building Water Systems <br /> 201 E.Washington Ave. <br /> In accord with ILHR 83.05,Wis.Adm.Code P.O.Box 7969 <br /> Madison,WI 5 707-7969 <br /> • Attach complete plans(to the county copy only)for the system,on paper not less County o <br /> than 8 112 x 11 inches in size. �,R At L3� Z /�� <br /> • See reverse side for instructions for completing this application State Sanitary Permit Number <br /> 3a53s1 <br /> The information you provide may be used by other government agency programs E]Check it revision to previous application <br /> (Privacy Law,s. 15.04(1)(m)j. State Plan I.D.Number U <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION I <br /> Prope y Owner Namefp roperty Location / <br /> �jVa D9lfL 61444. 3 ",S T 410,N, R/4 E(or)W <br /> Prope Own 's Mailing Address Lot Number B umbe <br /> !9ao Vrlfk) 'If . / �s� ✓ol 2. 43 G-L- 3 <br /> City State Zip Code Phone Number Subdivision Name or CSM Number <br /> Jlro�Tff ��� �>�✓, sso so (+d(,� )6r/�-97jD <br /> II. TYPE OF BUILDING: (check one) E] State Owned ❑ it� J`N�geZrest Road Ej Public 1 or 2 Famil Dwellin - No. of bedrooms C— Town ofCb•113L9(2� ' 1 `/ <br /> III. BUILDING USE: (If building type is public,check all that apply) Parcel Tax Number(s) <br /> 1 E] Apartment/Condo e a 8-- l , in/_�—b 1 <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.`SVew 2. ❑ Replacement 3_ ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an <br /> - System -- System ------------- Tank Only___ ______ Existing System_ ______ExistingSystem <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 /> 1 1ASeepage Bed 21 [:]Mound 30[-]Specify Type 41 E]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.Area3. Absorp.Area 4. Loading Rate 5. Perc. Rate 6. System Elev. 7. Final Grade <br /> Requir d (sq. ft.) Proposed(sq.ft.) (Gals/day/sq.ft.) (Min./inch) A Elevation <br /> 3� .� 1117 Feet 98 Feet <br /> TANK Capacit <br /> VII. INFORMATION in allons Gallons Ta f Manufacturer's Name Concrete con- Steel Fiber-ass ASite ppr <br /> Plastic <br /> New Existin strutted <br /> Tanks Tanks <br /> Septic Tank or Holding Tank SQ 75'0 Z AaL ❑ ❑ ❑ ❑ ❑ <br /> l ift Pump Tank/Siphon Chamber ❑ ❑ ❑ ❑ El El <br /> VIII. RESPONSIBILITY STATEMENT <br /> I,the undersigned, assume responsibility for installation of the onsite sewage system shown on the attachedplans. <br /> P er's Name:(Print) Plu - nat (No S raps MP/MPRSW No.: Business Phone Number: <br /> g� Rof+T �. a��6�0 7/s �4? -35-02 <br /> Plumber's Address(Street,City,State,Zip Code): LU / <br /> /�. 7/ 7,f-- RD 35- D AI6t /Zh, fV9'? <br /> IX. COUNTY/ DEPARTMENT USE ONLY <br /> ❑Disapproved Sanitary Permit Fee (Induces Groundwater ate Issue Issuing A e ,gnat ( o a s) <br /> roved Dv surchargeree) <br /> "app ❑Owner Given Initial / 5-o <br /> Adverse Determination !� <br /> `IDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> `� D6ixIBUTION'. Original t o Couray,One Copy To: Safety is Buildings Division,Owner,Plumter <br />