Laserfiche WebLink
Safety and Buildings Efivision <br /> '.�■■.nn SANITARY PERMIT APPLICATION Bureau of Building Water System: <br /> 201 E.Washington Ave. <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 County <br /> than 8 12 x 11 inches in size. u j l a Q 8 <br /> • See reverse side for instructions for completing this application State Sanitary reev P.ee�um er <br /> Te information you provide may be used by other government agency programs E]chec d vise//fon tD pr ",application <br /> [Privacy Law,s. 15.04(1)(m)]. <br /> State Plan I.D.Number <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION S97- o2/b S$ <br /> Prope�rty Owner Name Property Location A <br /> U 5 1/4 1/4,S Iq T 3 1 ,N, R 16 E(or&W <br /> Property Owner's Mailing Address Lot Number { r <br /> JS1(0 -StAwKISFE L14, 2 <br /> City,StateZip Code Phone Number Subdivision Name or CSM Number <br /> EA(4 C�(RIRE 1�/ , 6J170 3 ( > <br /> II. TYPE OF BUILDING: (check one) ❑ State Owned ❑ City Nearest Road <br /> e 9 <br /> Public 1 or 2 FamilyDwelling- No. of bedrooms Z o rowan OF M645140AI <br /> CK )9 Ss Lx RD. <br /> III. BUILDING USE: (If building type is public,check allthatapply) Parcel Tax Number(s) <br /> 1 ❑ Apartment/Condo O(S 331`f 02 Sn0 <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_ X New 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an <br /> ----- System --- System ----- ---- -- Tank-Only--------------- gy9y <br /> 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 ❑Seepage Bed 21 ❑Mound 30❑Specify Type 41 ❑Holding Tank <br /> 12❑Seepage Trench 22141n-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 /> 30C) 1 500 $00 G 9�•2"� Feet Feet <br /> VII. TANK Capac ty <br /> INFORMATION in gallons Total #of Manufacturer's Name Prefab- Site Fiber- plastic Exper. <br /> New Existin Gallons Tanks Concrete Con- Steel glass App_ <br /> strutted <br /> Tanks Tanks <br /> Septic Tank or Holding Tank -750 50 El <br /> Lift Pump Tank/Siphon Chamber Soo S00 ❑ El El ❑ Ej <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:(No tamps) MP/MPRSW No: Business Phone Number: <br /> tt- R AP141tis 1 715 8G6- /S7 <br /> PI mber's Address(Street,City,State,Zip Code): <br /> 27760 7qw;4 36 146of fm W1. 5`fs;93 <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑Disapproved Sanitary Permit Fee (1, ludesGrovndwater ate ssue Issuing Age Signa ure( S mps) <br /> �pproved El Owner Given Initial 0 Surchar9efee) <br /> Adverse Determination <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD.6398(R.05/94) DISTRIBUTION: Original to county.One copy To: Safety&Ruildings Division,Owner,Plumber <br />