Laserfiche WebLink
C 2 Safety and Buildings Division <br /> 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 I <br /> than 8112 x 11 inches in size. c�fit{2 - OZ/O� 1 <br /> • See reverse side for instructions for completing this application State Sanitary <br /> Permit Number <br /> The information you provide may be used by other government agency programs Check`F, e, sldn�pr�us application <br /> IPrivacy Law,s. 15.04(1)(m)]. State Plan I -Numb/err <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION N i�1— <br /> Property Owner Name Property Location <br /> L">,��j 1/4 1/4,S 5. T f� ,N, R /5--E(or)m <br /> Property Owner's Mailing Addresrs - Lot Number Block Number <br /> City,State Zip Code Phone Number Subdivision Newe-er-E3A4 Number <br /> 10i.-3 e SSS' 3/ 1(6/.? )i/3/Z-&/60 L <br /> II. TYPE BUILDING: (check one) ❑ State Owned ❑ city /� Nearest Road CR <br /> Public 1 or 2 FamilyDwelling- No. of bedrooms r� D Townn OFz-/4rt-o//e,4� G ¢//.4-g <br /> !II. BUILDING USE: (If building type is public.check all that apply) Parcel Tax <br /> GNuumber(s) �7 <br /> 1 r-1 Apartment/Condo l ! `r(4/ 5 6 / ��C) <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 g Replacement 3_ ❑ Replacement of q ❑ Reconnection of 5_ ❑ Repair of an <br /> ------System --------System -------- Tank Only---------------Existin 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❑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 6. S tem Elev. 7. Final Grade <br /> �© C) Required (sq.ft.) Proposed(sq.ftJ (Gals/day/sq. ft.) (Min./inch) Elevation <br /> 6 C'0 6G C) � S 'g Feet 10 %2 Feet <br /> VII. TANK <br /> Capacity <br /> in gallons Total #of er. <br /> Prefab. Site Fiber- Ex <br /> INFORMATION Gallons Tanks Manufacturer's Name Concrete Con- Steel App. <br /> Plastic p <br /> New Existing strutted glass <br /> Tanks Tanks <br /> Septic Tank or Holding Tank 21721 ❑ ❑ ❑ ❑ ❑ <br /> Lift Pump Tank/Siphon Chamber 5-00 jots ❑ ❑ ❑ ❑ ❑ <br /> VI11. 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 Stamps MP/MPRSW No.: Business Phone Number: <br /> ZJ Ade F-, h C& GJ� F A -�7A�/ <br /> Plumber's Address(Street,City,State,Zip Code): <br /> IX. COUNTY/ DEPARTMENT USE ONLY <br /> Disapproved Sanitary Permit Fee ncludesGroundwdter ate Issue liss7uinAtSign a No Stamps) <br /> pproved ❑Owner Given Initial `hw9e`ee) <br /> Adverse Determination 11,7 <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> 5131 639B(H.W94) DISTRIBUnnN'. Original to Cnunly,One tupy To: Safety 6 Buildings Dim-_ion,Owner,Pl.o,Wr <br />