Laserfiche WebLink
Safety and Bildings Divid <br /> Nvisconsin <br /> SANITARY PERMIT APPLICATION 201 W.Wa hingt n Avenuen <br /> bepartment of Commerce In accord with Comm 83.05,Wis.Adm.Code P O Box 7302 <br /> Madison,WI 53707-7302 <br /> • Attach complete plans(to the county copy only)for the system,on paper not less county <br /> than 81/2 x 11 inches in size. a3yy6 <br /> • See reverse side for instructions for completing this application St a Sanitary Permit Number �`' <br /> Personal information you provide may be used for secondary purposes 3 5_:±�OD--/) bi <br /> [Privacy Law,s. 15.04(1)(m)]. ❑Check if revision to prkvious application <br /> C(1oZ Et 4?. State Plan I.D.Number <br /> I. APPLICATION INFORMATION- PLEASE PRINT ALL INF RMATION <br /> Propert O"Na Property Location <br /> /4 1/4,S 'jj T ,N, R IR E(or� <br /> Property Owner.s Mailing Address Lo umber ���r <br /> C ,State 2 W1 Zi d P ne N tuber Subdivision Name or CSM Number ©orf <br /> -TYPEB DING: (check one) ❑ State Owned- ❑ ItyI Nearest Road <br /> Public 1 or 2 FamilyDwelling- No.of bedrooms 3 ToOF /V1 <br /> III. BUILDING USE: (If building type is public,check all that apply) Parcel Tax Number(s) <br /> 1 ❑ Apartment/Condo 614 D 3 I —ba <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 S stem 2.�S epelamement 3_ E] Replacement of 4_ ❑ Reconnection of 5. E] Repair of an <br /> y_____________y= ________-__-- TankOnly-___ _ Existing System ___ -____ExistingSystem <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 /> 1 Seepage Bed 21 ❑Mound 30 E]Specify Type 41 E]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 /> O Req fired(sq. ft.) Prop sed sq.ft.) (Gals/day/sq.ft.) (Min./inch) ��sj Elevation <br /> VII. TANK Capacity <br /> . 7 rte! q. -` Feet �Q- Feet <br /> INFORMATION in gallons Total #of Prefab. Site Fiber- Ex <br /> New Existin Gallons Tanks Manufacturer's Name concrete Con- Steel glass Plastic xppeev <br /> Tanks Tanks strutted <br /> Septic Tank or Holding Tank W ❑ ❑ ❑ ❑ <br /> Lift Pump Tank/Siphon Chamber ❑ ❑ ❑ 11VIII. 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) Plumb is Signat e: Stamps) MP/MPRSW No.: Business Ph ne Number: <br /> =51.51 s- - 41fs <br /> Plu ber's Address(S�eet, i ,State,Zip Code <br /> 1- 3 <br /> IX. COUNTY/DEPARTKAENT USE ONLY <br /> ❑Disapproved Sanit ry Permit Fee tindudetGroundwater Date/, Issuing gent Signature(No Stamps) <br /> Approved ❑Owner Given Initial Surcharge Fee) u— `!o � <br /> Adverse Determination /��' vv <br /> X. ONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(R.4/99) DISTRIBUTION: Original to County.One copy To: Safety&Buildings Division,owner,Plumber <br />