Laserfiche WebLink
��, Safety an Buildings Dlvfsrion <br /> .�w SANITARY PERMIT APPLICATION 201 W.Washington Avenue <br /> onsin In accord with ILHR 83.05,Wis.Adm.Code Madison,ox WI253707- 302 <br /> Department of Commerce <br /> • Attach complete plans(to the county copy only)for the system,on paper not less county <br /> than 8112 x 11 inches in size. 6 Q1—/(/e_ rJ {� <br /> • See reverse side for instructions for completing this application State Sanitar�rm it Number T� <br /> Personal information you provide may be used for secondary purposes ❑check A revision to previou3 appbcation <br /> [Privacy Law,s. 15.04(1)(m)]. State Plan I.D.Number Q <br /> I. APPLICATION INFORMATION- PLEASE PRINT ALL INF RMATI N e/ �(� S <br /> Property Owner Name Property Location <br /> KA-rl 1—o h 1/4 1/4,S 17 T�3,p N, RIZ E(orX'S") <br /> PropertOwner's Mailing Address / Lot Number Block Number <br /> 7-7 7 E o o� /�/9 r l�'-�r— 1 -7 <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> ll. TYPE OF BUILDING: (check one) ❑ State Owned ❑City <br /> /� Nearest Road/ <br /> Public or 2 Family Dwelling-No.of bedrooms Village <br /> OF �/�{N�C/s <br /> III. BUILDING USE: (If building type is public,check all that apply) Parcel Tax/Number(ss)7 / <br /> 1 ❑ Apartment/Condo 06 d d `� <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. 5g 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 Wolding 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. 17. Final Grade <br /> /�_� Required(sq.ft.) Proposed(sq.ft.) (Gals/day/sq.ft.) (Min./inch) Elevation <br /> -/ r— I Feet Feet <br /> TANK Ca at <br /> VII. INFORMATION in ealo s Total #of Prefab. Site Fiber- Exper <br /> g Gallons Tanks Manufacturers Name Concrete Con- Steel glass Plastic App <br /> New Existing! strutted <br /> Tanks I Tanks 1 14 <br /> SepticTankorHoldingTank Dc) Paa ❑ ❑ ❑ ❑ ❑ <br /> Lift Pump Tank/Siphon Chamber ❑ ❑ ❑ ❑ ❑ ❑ <br /> Vlll. RESPONSIBILITY STATEMENT <br /> 1,the undersigned,assume responsibility for installation of the onsite sewage system shown on the attached plans. <br /> Plumber's Name:(Print) Plumber's Signature:(N Stamps) MP/MPRSW No.: Business Phone Number: <br /> Plumber's Address(Street,City,State,Zip Code): <br /> 4 a,]r S/ si,^c.%-) S y S-7,-- <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑Disapproved Sanita Permit Fee (Includes Groundwater ate IssuedIssuing nt Sign ure( a ps) <br /> S harge Fee) <br /> Approved ❑Owner Given Initial ,s 116-13 47 <br /> Adverse Determination ' <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(8.11/97) DISTRIBUTION: Original to County.One copy To: Safety a Buildings Division,Owner,Plumber <br />