Laserfiche WebLink
afMet y and Building Division <br /> SANITARY PERMIT APPLICATION Bureau of Building Water Systems <br /> ri�L�7�7 201 E.Washington Ave. <br /> In accord with I L H R 83.0 5,Wis.Adm.Code P .Box 7969 <br /> Madison,WI 53707-7969 <br /> • Attach complete plans(to the county copy only)for the system,on paper not less Coutity / <br /> than 8 112 x 11 inches in size. <br /> • See reverse side for instructions for completing this application State Sanitary Permit Number <br /> The information you provide maybe used by other government agency programs ElCheck it revision to pr�evioouus application ��9�11 <br /> [Privacy Law,s. 15.04(1)(m)]. State Plan I.D.Number l.P' <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION <br /> Property 5W1p <br /> n�Name PropertyLoc ti n$ T N R W <br /> Property Owner's Mailing Address ,y A Lot Number Block Numb'er <br /> G <br /> C_iUlState t Zip Code Phone Number Subdivision Name or CSM Number <br /> l�irC <br /> Ir TYPE F BUILDING: (check one) ❑ State Owned 'ty Nearest Road <br /> ❑ Village C. ��� /1/J <br /> Public 1 or 2 Family Dwelling- No.of bedrooms Town OF u7 U <br /> III. BUILDING USE: (If building type is public,check all that apply) Parcel TaxNumber(s)3 <br /> 1 ❑ Apartment/Condo <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 2. E] Replacement 3. L] Replacementof 4. ❑ Reconnection of 5_ E] Repair of an <br /> System <br /> ---- --- - 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 /> 11Seepage Bed 21 ❑Mound 30 E]Specify Type 41 E]Holding Tank <br /> 12 H Seepage Trench 22❑In-Ground Pressure 42❑Pit Privy <br /> 13❑Seepage Pit 43❑Vault Privy <br /> 14❑System-]n-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 /> 4;�'o 0 Required(sq. ft.) Propo ed(s . ft.) (Gals/day/sq.ft.) (Min./inch) Elevation <br /> 455-7 '16 -� t3"5 r 0 Feet $9 r 0 Feet <br /> VII. TANK Capacity site <br /> in gallons Total #of Prefab. Fiber- plastic Exper <br /> INFORMATION Gallons Tanks Manufacturer's Name Concrete Con- Steel glass App <br /> New ]Existing strutted <br /> Tanksl Tanks pp�� <br /> Septic Tank or Holding Tank 00 0 x000 a�Oa El ❑ ❑ ❑ ❑ ❑ <br /> Lift Pump Tank/Siphon Chamber ❑ ❑ ❑ ❑ ❑ ❑ <br /> VIII. RESPONSIBILITY STATEM N <br /> I,the undersigned,assume responsibility for installation of the onsite sewage system shown on the attached plans. <br /> Plumber's Name:(Print) Plumber' Signature No t/amps) MP/MPRSW NO.: Business Phone Number: <br /> Plumber's Address(Street,City,State,Zip Code). <br /> 5�d ' 7'' L G�-e� �s C [��S <br /> IX. COUNTY/ DEPARTMENT USE ONLY <br /> ❑Disapproved Sanitary Permit Fee (IndudesGroundwater Date ssue Issuing Agent Si nature o 5 s) <br /> ❑Approved ❑Owner Given Initial /� p0 Surcharge Fee) <br /> Adverse Determination v ' Z��9 <br /> X. CONDITIONS OF APPROVAL/ REAS SFO DIS;Z�_60 <br /> ROVAL: <br /> �X Ivey 1& OZY"3R) C_ llh%y//>Yf 4 417 0_�_ T� <br /> SND-6398(R.0S/94) DIS IBOTIOW Original Cou y.One copy To: Safety B Ruildings Divulon,Owner,Plumt�r <br />