Laserfiche WebLink
Safety and Buildings Division <br /> X1011.,iR SANITARY PERMIT APPLICATION Bureau of Building Water Systems <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 Count /9 <br /> than 812 x11 inches in size. 2L"nAlc <br /> • See reverse side for instructions for completing this application State Sanitary Permit Number <br /> The information you provide may be used by other government agency programs ❑Che revi o previous application <br /> (Privacy Law,s. 15.04(1)(m)). State Plan I.D.Number A 11 <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION M <br /> Prop IOwner Name `� /�// jr Property `iia 5 T Seo ,N, R l�/E(or(2) <br /> Property Owner's Mailing Address Lot Number Block Number <br /> City,Stase <br /> Zip Code Phone Number Subdivision Name or CSM Number <br /> nJdove(/' /1 /1. 5o (6/;?) S7G/S6 <br /> 54P <br /> II. TYPE OF BUILDING: (check one) ❑ State Owned ❑ City Nearest Road <br /> ❑ Village <br /> Public 1 or 2 Family Dwelling- No of bedrooms -� own of SCd <br /> III. BUILDING USE: (If building type is public,check all that apply) Parcel Tax Number(s) <br /> 1 ❑ Apartment/Condo O � �1/0ff 05 .3 <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. 1ri;iLNew 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an <br /> S_�_System System Tank Only---------------Existing System __ 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 ❑Seepage Bed 21 ❑Mound 30❑Specify Type 41 ❑ Holding Tank <br /> 12 IRSeepage Trench 22❑ In-Ground Pressure 42❑Pit Privy <br /> 13❑Seepage Pit �iu1 Mr llt,4 43❑Vault Privy <br /> T <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 /> 7! 5� Required (sq. ft.) Proposed(sq. ft.) (Gals/day/sq.ft.) (Min./inch) Elevation <br /> 7l 5 �.3 -5—e--7 , 21 Fx g Feet ,97 3 Feet <br /> Capacit VII. INFORMATION in llons Total #of Prefab site Fiber- Exper <br /> g Gallons Tanks Manufacturers Name concrete Con- Steel glass Plastic App <br /> New Existin strutted <br /> Tanks Tanks <br /> Septic Tank or Holding Tank QQ� Q� ❑ ❑ ❑ ❑ ❑ <br /> Lift Pump Tank/Siphon Chamber ❑ ❑ ❑ ❑ ❑ ❑ <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:(Prin Plumber's Signature: Stamp ) MP/MPRSW No.: Business Phone Number: <br /> z�Ac <br /> Plumber's Address(Street,City,Stat,Zip Code): le <br /> X149it' -5-15011 s//' e_^_J W7r- <br /> IX. COUNTY/ DEPARTMENT USE ONLY <br /> ❑Disapproved Sanitary Permit Fee (Includes Groundwater ate uejssuin nt Sig N ) <br /> Surcharge feel <br /> Approved ❑Owner Given Initial �� aQ <br /> Adverse Determination O <br /> X. CONDITIONS OF APPROVAL/REASONS ISAPPROVAL: <br /> SHU-6398(H.05/94) DISTRIBUTION: Original to Courdy.One Copy To: Suety 8 Buildimy Division,Owner,Plumber <br />