Laserfiche WebLink
Safety Bui�vision <br /> SANITARY PERMIT APPLICATION 201 W.Washington Avenue <br /> P O Box 7302 <br /> N isvolllsin In accord with Comm 63.05,Wis.Adm.Code Madison,WI 53707-7302 <br /> Department of Commerce <br /> • Attach complete plans(to the county copy only)for the system,on paper not less County 3 57Zrb <br /> than 8 vz x 11 inches in size. St a Sanitary Perrtimber <br /> • See reverse side for instructions for completing this application J1 .�Ji Q <br /> Check if revision to previous application <br /> Personal information you provide may be used for secondary purposes State Plan I.D.Number <br /> [Privacy Law,s. 15.04(1)(m)1- t� <br /> 1. APPLICATION INFORMATI N - PLEASE PRINT ALL IN RMA T ONerty ocation <br /> Property Owner Name 1/4 1/4,S 5 T ,N,R 1(.0 E(or <br /> Lot Number Block Number <br /> Propert Owner's Mailing Address <br /> City, tate 33 Zi Code Phone Number Subdivision Name or CSM Number j�✓IQ <br /> 601Nearest Road <br /> I . T P ILDING: (check on ❑ State Owned o village $SOMI <br /> Public 1 or 2 FamilyDwelling-No.of bedrooms Town OF <br /> e <br /> CK) ' <br /> II that apply) Parcel Tax Number(s) en <br /> ) 10 <br /> III. BUILDING USE: (If building type ispu © � �3s O3 <br /> � <br /> 1 ❑ Apartment/Condo D�10 [3 Outdoor Recreational Facility <br /> 2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home <br /> El Campground 7 F1 Merchandise: Sales/Repairs 11 ❑ RestaurantBar/Dining <br /> 3 <br /> Mobile Home Park 12 C] Service Station/Car Wash <br /> 4 ❑ Church/School 8 13 ❑ Other: specify <br /> office/Factor <br /> 5 ❑ Hotel/Motel 9 ❑ y <br /> IV. TYPE OF PERMIT: (Check only one box on line A. Check box on line B,if applicable) <br /> Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an <br /> A) 1 New 2. ❑ Replacement 3. ❑ Existin System _ _ Existing System <br /> _ stem -_System ------------- Tank -----------------nly ----- 9 -y-------- <br /> -y---------- <br /> Date Issued <br /> B) ❑ A Sanitary Permit was previously issued. Permit Number <br /> V. TYPE OF SYSTEM: (Check only one) Other <br /> Pressurized Distribution Experimental <br /> Non-Pressurized Distribution 41 Holdin Tank <br /> 11 Seepage Bed 21 ❑Mound 30❑Specify Type ❑ g <br /> 22 In-Ground Pressure 42❑Pit Privy <br /> 12 Seepage Trench ❑ 43❑Vault Privy <br /> 13❑Seepage Pit <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 rade <br /> Required(sq.ft.) Proposed(sq.ft.) (Gals/day/sq.ft.) (Min./inch) �S -7 Feet E.LIS-IO Feet <br /> ISDo 1 2 4 21 1 <br /> Capacity Prefab. Site Fiber- plastic Exper <br /> VII. TANK in gallons Total #of Manufacturers Name Concrete Con- Steel glass Apo <br /> INFORMATION New Existin Gallons Tanks strutted <br /> Tanks Tanks �7 $44 ❑ ❑ ❑ El <br /> Septic Tank or Holding Tank `� <— ❑ ❑ ❑ <br /> ❑ ❑ ❑ <br /> Lift Pump Tank/Siphon Chamber <br /> VIII. RESPONSIBILITY STATEMENT <br /> for installation of the onsite sewage system shown on the attached plans. <br /> I,the undersigned,assume responsibility <br /> MP/MPRSW No.: Business Phone Number: <br /> Plumber's Name:(Print Plumber's5ignature: No mps) I J <br /> ck}y{Rp P)Q4 Z2S g s( (S- �fi' <br /> Plu ber's Address(Street,Cit ,State,Zip Code): 1 <br /> two0 <br /> W. COUNTY/ DEPARTMENT USE ONLY <br /> E[]Disapproved Sanit Permit Fee (includesgGroundwater ate ssue Issuing Age t5 natur (N t <br /> ` char eFee) / .t` 77rovedOwner Given Initial 175 l OH <br /> Adverse Determination <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> DISTRIBUTION: Original to County.One copy To: Safety 8 Buildings Division,Owner,Plumber <br /> \ �?.4199) — --------— <br />