Laserfiche WebLink
Safety and Buildings Division <br /> Visconsin SANITARY PERMIT APPLICATION 201 W.Washington Avenue <br /> In accord with ILHR 83-05,Wis.Adm.Code P O Box 7302 <br /> Department of Commerce Madison,WI 53707-7302 <br /> Attach complete plans(to the county copy only)for the system,on paper not less County <br /> than 8 1/2 x 11 inches in size. <br /> • See reverse side for instructions for completing this application St e Sanitaarry Perini um�Typr <br /> Personal information you provide may be used for secondary purposes L]ch,� r revisi o pre®us application <br /> (Privacy Law,s. 15.04(1)(m)]. State Plan I.D.Number <br /> 1. APPLICATION INFORMATION- PLEASE PRINT ALL INF RMATION 1 <br /> Property Owner Name Property Location <br /> va NLJ va,S 1;?— T 2 N,R 1� E(or W <br /> Propert 'Owner's Mailin Address Lot Number <br /> City State Zi Code Phone Number Subdivision Name or CSM Number <br /> 1 <br /> II. TYPE OF BUILDING: (check one) ❑ State Owned City e Nearest Road <br /> El ❑Vag <br /> Public 1 or 2 FamilyDwelling-No.of bedrooms Towiln OF iAuoA <br /> III. BUILDIN USE: (If building type is public,check all that apply) Parcel TaxNumber(s) <br /> 1 ❑ Apartment/Condo i DIS 3312 01 MCI <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. Ivf New 2. ❑ Replacement 3. ❑ Replacement of 4_ ❑ Reconnection of 5_ ❑ Repair of an <br /> System System _ ____ _ Tank Only____ _ _____ Existing System ________ E----xistinQSyste- <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 /> 1Seepage Bed 21 ❑Mound 30 E]Specify Type 41 ❑Holding Tank <br /> 1 E3 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.ft.) (Min./inch) Elevation <br /> �---- (7.D Feet 93.5 Feet <br /> Ca aclt <br /> VII. alto s Total #of Prefab. Site Fiber- Exper. <br /> INFORMATION in <br /> g Gallons Tanks Manufacturers Name Concrete Con- Steel glass Plastic App <br /> New Existing strutted <br /> Tanks Tanks <br /> Septic Tank or Holding Tank K ❑ ❑ ❑ <br /> Lift Pump Tank/Siphon Chamber ❑ Ej 0 0 <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 Signature,(N amps) M/P//MMPRRSSW�jNo.: Business Phone Number: <br /> /�JLa7 Z7�l /�- <br /> PI ber'sAddress( treet,city, te,Zip Code). <br /> (00 L,l _ Sq g93 <br /> IX. COUNTY/DEPAR M T USE ONLY <br /> ❑Disapproved Sa itary Permit Fee QndudesGroundwater ate IssuedIssuing Ag7Si r ( Stamps) <br /> +9� roved �j}�rgefee) <br /> p ❑Owner Given Initial / 75 / It�c,� <br /> Adverse Determination l / GG <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> aA In, <br /> bl� tom <br /> SBD-6398(R.11/97) DISTRIBUTION: Original to County.One copy To: Safety 6 Buildings Division,Owner,Plumber <br />