Laserfiche WebLink
Visconsin <br /> Safety and Buildings Division <br /> SANITARY PERMIT APPLICATION 201 E.Washington Ave. <br /> In accord with ILHR 83.05,Wis.Adm.Code P.O.Box 7969 <br /> Department of Commerce Madison,WI 53707-7969 <br /> • Attach complete plans(to the county copy only)for the system,on paper not less count <br /> than 8 12 x 11 inches in size. c.a/,no e.. <br /> • See reverse side for instructions for completing this application State Sanitary Permit r�Vft r <br /> The information you provide may be used by other government agency programs ❑Check F, ",n to previo(sm�pplication 1 T <br /> IPrivacy Law,s. 15.04(1)(m)]. State Plan I_D.Number ,r , <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INF RMATION /IV/ <br /> Pro erty Owner Name Property Location od Z <br /> c � GJ 1/4 N4✓ 1/4,S T�� •N- R 17E(or)© <br /> Property Owner's Mailing Address Lot Number Block Number <br /> /0 9 A) cJz- of u e,0 --- <br /> City,State/ i Zip Code Phone Number Subdivision Name or CSM Number <br /> II. TYPE F B ILDIN : (check one) ❑ State Owned ❑ it t Nearest Road <br /> Village <br /> Public 1 or 2 FamilyDwelling ❑-No.of bedrooms _ own OF r e lS 7U <br /> III. BUILDINGUSE: (If building type is public,check all that apply) Parcel TaxNum(bber(s) <br /> 1 ❑ Apartment/Condo T �0/ <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 online A. Check box online B, if applicable) <br /> A) 1. ❑ New 2. gReplacement 3. ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an <br /> System - System - _ ------- Tank-Only_______________ExistingSystem -______ 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 VLSeepage 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 6. System Elev. 7. Final Grade <br /> / Required (sq.ft.) Proposed(sq.ft.) (Gals/day/sq.ft.) (Min./inch) Elevation <br /> 6 C c) Ovo-v /4;2 oe) . -S- I 9 ld 3 Feet 9799 Feet <br /> Capacity VII. TANK in gallons Total #Of r Prefab. Site Fiber- Exper <br /> INFORMATION g Gallons Tanks Manufacturer s Name Concrete Con- Steel glass Plastic App <br /> New ExiStin strutted <br /> Tanks Tanks <br /> Septic Tank or Holding Tank OR <br /> ❑ ❑ ❑ ❑ ❑ <br /> Lift Pump Tank/Siphon Chamber p o1 ❑ ❑ ❑ ❑ ❑ <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:(Fir in Plumber's Signature:(No Stamps) MP/MPRSWNo.: Business Phone Number: <br /> LJ 1 a s�6l �� 19 Y�-7� � <br /> s� <br /> Plumber's Ac dress(Street,City,State,Zip Code): <br /> 1-J <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑Disapproved Sanitary Permit Fee (indvdesGroundwater ate ssue Issuing A ignatu ) <br /> roved / /}�GtfhargeFee) p <br /> p ❑Owner Given Initial .�" 7—` <br /> Adverse Determination7-5r If <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(R.1196) DISTRIBUTION: Original to County,One copy To: Safety 8 Buildings Division,Owner,Plumber <br />