Laserfiche WebLink
Safety and Buildings Division <br /> ^;-,"n": Bureau of Building Waters stem. <br /> ���..... SANITARY PERMIT APPLICATION sot a of Building Ave y <br /> In accord with ILHR 83.05,Wis.Adm.Code P.O.Box 7969 <br /> Madison,WI 53707-7969 <br /> • Attach complete plans(to the county copy only)for the system,on paper not less countJ <br /> than 8 112 x 11 inches in size- ,D C:/-/ <br /> • See reverse side for instructions for completing this application state Sangry Permit Number? �l <br /> The information you provide may be used by other government agency programs ❑Citefc�ckk it r vision/\to previous application <br /> [Privacy Law,s. 15.04(p(m)). <br /> State Plan I.D.Number <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION <br /> Propert wner ameProperty Location <br /> c/v4 v4,S ' g ,N, R E(or <br /> Property ner's Mailing Arens Lot Number Block Number <br /> 2 o —� <br /> City,State Zip Code Phone Number Subdivision Name orM Nurgbd <br /> re t ti 1 7! - _QVC <br /> II. TY OF BUILDING: (check one) [j State Owned [3ity Nearest Road <br /> Public 1 or 2 Famil Dwellin - No. of bedrooms �_ Town of #L <br /> 111. BUILDING USE: (If buildingtype ispublic,check allthatapply) Parcel Tax Number(s) <br /> 1 ❑ Apartment/Condo 2-Ll- 3113 -oy- 700 <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. CNew 2 ❑ Replacement 3. ❑ Replacement of q ❑ Reconnection of 5- ❑ Repair of an <br /> System System _ Tank Only __ Existing Sys em Existing System <br /> B) ❑ A Sanitary Permit was previously issued. Permit Number Date Issued <br /> V. TYPE OF SYSTEM: (Check only one) <br /> Nom Pressurized Distribution Pressurized Distribution Experimental Other <br /> 11 Wseepage 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-Fill <br /> VI. ABSORPTION SYSTEM INFORMATION: <br /> 1. Gallons Per Day 2. Absorp.Area 3. Absorp.Area 4. Loading Rate 5. Perc. Rate . System Elev. 7. Final Grade <br /> 3 O© Required(sq. ft.) Proposed (sq. ft.) (Gals/day/sq.ft.) (Min./inch) Elevation <br /> 7 NJQ Feet CfQ,O Feet <br /> TANK Capacit <br /> VII. INFORMATION in allons Total #of Manufacturer's Name Prefab rt Fiber- Plastic Exper <br /> New Exist in <br /> Gallons Tanks concrete Steel glass App <br /> ]Tanks Tanks ) sv cted <br /> Septic Tank or Holding Tank g00 00 /7!/ (� ❑ n ❑ El <br /> Lift Pump Tank/Siphon Chamber, ❑ ❑ ❑ 1-1 Ej <br /> VIII. RESPONSIBILITY STATEMENT <br /> I,the undersigned,assume responsibility for installation of the onsite sewage system shown n the attached plans. <br /> Plumber's Name:(Print) Plumber' S gnature:(No St ps) MP/MPRSW No.: Business Phone Number: <br /> /f( 3 ° G� 715-V.Iv—Z6 <br /> Plum <br /> lkt�J rl's Addr ss(Street,City,State,Zip odolp, <br /> 1 t C cJ 7 <br /> IX. COUNT / DEPARTMENT USE ONLY <br /> E]Disapproved Sanitar Permit Fee (includes Groundwater ate Issue Issu ng tSi na e o mps) <br /> hergefee) <br /> Approved ❑Ownes Deternitial 1�c\ CI�� <br /> Adverse Determination <br /> X. CONDITIONS OF APPROVAL/ REASONS FOR DISAPPROVAL: <br /> SNU-ti398IN.0519nl DISTRIBUTION- Originalm Cnl101y,OnecnPyTo. S.dety B BuiI'111195 rivnian.Owner,Plum r <br />