Laserfiche WebLink
Safety and Buildings Division <br /> SANITARY PERMIT APPLICATION 201 W.Washington Avenue <br /> d <br /> `066on5%D P 0 Box 7302 <br /> [%partment of Commerce In accord with Comm 83.os,Wis.Adm.Coe Madison,WI 53707-7302 <br /> • Attach complete plans(to the county copy only)for the system,on paper not less <br /> than 8112 x 11 inches in size. GlY✓f� J -7 <br /> See reverse side for instructions for completing this application State Sanitary Permit Number <br /> Personal information you provide may be used for secondary purposes E]checMevn to 53 previous application <br /> (Privacy Law,s. 15.04(1)(m)]. State Plan I.D.Number <br /> _r <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INIF MATT N IT l� <br /> Firq�erty Owns{Na ` 1 Prgpert Location <br /> L>eL 1 Lt !. JO r 1 ri /�{Lv(ia t(f(f/t/a,S (Z T -37 ,N, R /8'•F,for <br /> Property Ow p er's Mailing Ad ress ' Lot Number El Numb@r <br /> Ci 'S Zip Code Phone Number Subdivision Name CSM um �S 7' S <br /> Ixer<< r. <br /> S`� 3 t7iS>327 88� r , '� _ <br /> II. PE BUILDING: (check one) ❑ State Owned ❑ ity / v N crest Road /� <br /> 2 ❑ VIIwn .� _4e !�Fe X 1p 0"- Ltt retfeeSS <br /> El Public 1 or 2 Family Dwelling-No.of bedrooms J own of cmc <br /> III. BUILDING USE: (If building type is public,check all that apply) Parcel TaxNumber(s) <br /> 1 ❑ Apartment/Condo 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 on line A. Check box online B, if applicable) <br /> A) 1 New 2. ❑ Replacement 3. ❑ Replacement of 4_ ❑ Reconnection of 5_ ❑ Repair of an <br /> System System Tank Only _ Existing System __ Existing System <br /> ------- ------------- ------------------------ ------------ <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 [KjSeepage 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. Absorp7.5�' 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.) ( 'n./inch) Elevation <br /> �f . 7 02 , I Feet ISS•I Feet <br /> VII. TANK Capacity Site <br /> in gallons Total #of Manufacturer's Name Prefab. Con- Steel Fiber- Plastic Aper. <br /> INFORMATION New ExistingGallons Tanks Concrete strutted glass App. <br /> Tanks Tanks r,� <br /> Septic Tank or Holding Tank W I Lt leos4r- "r 0 � � � ❑ <br /> Lift Pump Tank/Siphon Chamber Q 0 El ❑ El <br /> VIII. RESPONSIBILITY STATEMENT <br /> I,the undersigned,assume responsibi ity for installation of the onsite sewage system shown on the attached plans. <br /> Plumbers Name-(Print) Plu ber' Signatur ,(No amps) MP/MPRSW No.: Business Phone Number: <br /> Plumber's Address(Street Ci y,State, ipCode): r /pp-3 <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> (Includes Groundwater Date Issued Issuing Agent Signature( mps) <br /> E]Disapproved Sanitary Permit fee <br /> Surcharge fee) <br /> J"proved ❑Owner Given Initial 41 — (� -�2-00 <br /> Adverse Determination 7-5 e <br /> X. CON DITI N O PRO L/HE SO FOR DISAPPROVAL: f <br /> C(a SS�— <br /> �pqu(r,A Ct{ ou l 7,-Lo & h a la <br /> DISTRIBUTION: Original to County.One copy To: Safety&Buildings Division,owner,Plumber <br /> SBD-6398(R.4/99) <br />