Laserfiche WebLink
V 3 l comp <br /> Safety and Buildings Division <br /> SANITARY PERMIT APPLICATION <br /> 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 County <br /> than 8112 x 11 inches in size. IS Ur <br /> • See reverse side for instructions for completing this application Stat Sanitary P rm t Numbera� <br /> � ' ./ <br /> The information you provide may be used by other government agency programs El Check if renspif to previous application <br /> (Privacy Law,s. 15.04(1)(m)I. State Plan I.D Number <br /> 1. APPLICATION INFORMATION - PLEASE PRINT ALL INFO ATION <br /> Property Owner Name ,J Property Location ,may <br /> 74-,4lit% /v G� /� SN 1/4 Sal 1/4,S '02 T �" .N, R�� E(or)CY' <br /> Property Owner'sMatting Address Lot Number Block Number <br /> a J -3rj �� J O cJ <br /> City,Stax Zip Code Phone Number Subdivision Name or CSM Number <br /> Sou/ S� AJl h12) s c 7� (6�2 )S s 7-037 <br /> II. TYPE OF BUILDING: (check one) E] State Owned ❑ city Nearest Road <br /> Village <br /> [I / <br /> Public 1 or 2 FamilyDwelling- No.of bedrooms Town of lne- IUO ry vU, <br /> Ill. BUILDING USE: (If building type is public,check all that apply) Parcel Tax Number(s) <br /> 1 ❑ Apartment/Condo ) _3300� <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 ❑ Servic Station/Car Wash <br /> 5 ❑ Hotel/Motel 9 ❑ Office/Factory 13 ❑ Other specify <br /> IV. TYPE OF PERMIT: (Check only one box on IineA. Check box on line B, if applicable) <br /> A) 1. P'New 2_ ❑ Replacement 3_ ❑ Replacement of 4. ❑ Reconnectic n of 5. ❑ Repair of an <br /> 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 R Seepage Bed 21 ❑Mound 30❑Specify Type 41 ❑ 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 System Elev. 7. Final Grade <br /> Required (sq.ft.) Proposed(sq.ft.) (Gals/day/sq.ft.) (Min./inch) Elevation <br /> Feet 9� Feet <br /> TANK Ca aut <br /> VII. I FORMATION in gallons Total #of Manufacturer's Name Prefab o, <br /> Fiber- Plastic Aper <br /> New ExiStin GdllOns Tanks Concrete str cted Steel glass App. <br /> Tanks Tanks <br /> Septic Tank or l.Lol.linn Tank ge56 El ElElEl <br /> Lift Pump Tank/Siphon Chamber ❑ ❑ ❑ 1 ❑ 1 ❑ <br /> VI11. RESPONSIBILITY STATEMENT <br /> I,the undersigned, assume responsibility for installation of the onsite sewage system shown n the attached plans. <br /> Plumber's Name:(Print) Plumber's Signature: No Stamps) /MPRSW No : Business Phone Number: <br /> Ailsa <br /> Plumber's Address(street,City,State,Zip Coye): _ <br /> O e!3 foil'' —75/i/' . --L-! J✓.—�'&—2---2— <br /> IX COUNTY/ DEPARTMENT USE ONLY <br /> [:1 Disapproved Sanitary Perm,tFee (tori°dee Groundwater ate slue su ng A ent Signature(No Stamps) <br /> Approved oannrgele ) �� (� <br /> pp ❑Owner Given Initial )L �JL <br /> Adverse Determination <br /> X. CONDITIONS OF APPROVAL/ REASONS FOR DISAPPROVAL: <br /> SND-6398(it 05194) DISTRIBUTION- Original in Cnuriy,One uePy To: SAO,B Building,Dim:ion,Owner,Plum r <br />