Laserfiche WebLink
Safety and Buildings Division <br /> i:•p`II��', 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 Co.bLnty <br /> than 8 112 x 11 inches in size. j <br /> • See reverse side for instructions for completing this application S ate Sanitary Permit ,NNuummber Q <br /> The information you provide may be used by other government agency programs Check Ei �previo 1. 1. <br /> [Privacy Law,s. 15.04(1)(m)]. State Plan I .Number ,( / <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION I /V <br /> Pro=CtyOwner Name Property Location <br /> 1/4 1/4,S t3 T ,N, R l5 E(or& <br /> Proprt Owner's Mailing Address Lot Number Block Number <br /> [ LOS ALAMDs p9_ 13 <br /> City,State Zi Code P one Number Su ivision Name or CSM Number <br /> O FL. t > .� I1 SA - <br /> II. TYPE OF BUILDING: (check one) ❑ State Owned E] L.Ity Nearest Road <br /> Village <br /> Public 1 or 2 FamilyDwelling-No.of bedrooms 3 Town OF:TACKsoo ILKA C-f <br /> III. BUILDING USE: (If building type is public,check all that apply) Parcel Tax Number(s) <br /> 01z g42s 02 300 <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. ❑ Replacement 3. ❑ Replacement of 4. ❑ Reconnection 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�A 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. System Elev. 7. Final Grade <br /> O Req 'red (sq.ft.) Pro osed(sq.ft.) (Gals/] y/sq.ft.) (Min./inch) �1 Elevation <br /> ��-' 5.4 Feet 97. 9 Feet <br /> Ca aut <br /> VII. Site <br /> FORMATION in gallons Total #of Manufacturer's Name Prefab. Con- steel Fiber- Plastic Exper. <br /> New ExistingGallons Tanks Concrete strutted glass App. <br /> Tanks Tanks <br /> Septic Tank.or Holding Tank -an 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:(Print) Plumber's Signatur :(N tamps) MP/MPRSW No.: 71115- <br /> Business Phone Number: <br /> s 3+2L 96(0- 415-7 <br /> P umber's Address(Street, ity,State,Zip Code) If <br /> '002-1_7b0 gal 13 <br /> IX. COUNTY/ DEPARTMENT USE ONLY <br /> ❑Disapproved Sanitary Permi a Surcharge fee)(In`ude>6roundwaTer ate Issue Issuing Ayesign u tamps) <br /> roved ❑Owner Given Initial <br /> Adverse Determination <br /> X. CONDITIONS OF APPROVAL/ REASONS FOR DISAPPROVAL: <br /> SHO-639H(It.05/94) DISTRIBUTION: original to(ouray,One copy Ta: safety 8 RuilJings Divi ion,Owner,Plumtw <br />