Laserfiche WebLink
ft (!�)A/ <br /> SANITARY PERMIT APPLICATION Safety and Building <br /> ors Division <br /> Bureau of Buildin Water S <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 8 1/2 x 11 inches in size. 15 <br /> U <br /> • See reverse side for instructions for completing this application State Sanitary Permit Nu ber <br /> �i 910 <br /> The information you provide may be used by other government agency programs ❑Check it revision to previous application <br /> (Privacy Law,s. 15.04(1)(m)]. State Plan I.D.N.UMber <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION9-7447 <br /> Propt�y Owner Nam- Property Loc tions 2.4 T ,N, R I1 E(or W <br /> Property Owner's Mailing Address Lot Number Block Number <br /> 821 5M ID4 Rn . <br /> CitState Zip Code Phone Number Subdivi ion me or CSMW ber <br /> yQEB R ( ( > k- <br /> V <br /> I1. TYPE OF BUILDING: (check one) ❑ State Owned o city Nearest Road <br /> Village <br /> ❑ Public X 1 or 2 Family Dwelling-No. of bedrooms 3 Town OF CD <br /> II1. BUILDIN USE: (If building type is public,check all that apply) Parcel TaxNumbeer(s) '1001 <br /> 1 F1 Apartment/Condo M 4 1 O' q's^ <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. '-'R 3_ E] Replacement of 4. E] Reconnection of 5. ❑ Repair of an <br /> System 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 /> 11 ❑Seepage Bed 2�ound 30[_1 Specify Type 41 ❑Holding Tank <br /> 12 E] ❑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.Area3. Absorp.Area 4. Loading Rate 5. Perc. Rate 6. System Elev. 7. Final Grade <br /> Required(sq. ft.) Fir sed(sq.ft.) (Gals/day/sq. ft.) (Min./inch) QLD Elevation <br /> o o <br /> S 1. Z� 016 — 1-1 •`3 Feet 101 _91 Feet <br /> Capacity VII. FORMATION in gallons Total #of Manufacturer's Name Prefab. Coy Steel Fiber- App. <br /> Gallons Tanks Plastic <br /> New ExistingConcrete strutted glass App. <br /> Tanks Tanks <br /> Septic Tank or Holding Tank O ❑ ❑ ❑ ❑ ❑ <br /> Lift Pump Tank/Siphon Chamber w ❑ ❑ ❑ ❑ ❑ <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- 0 <br /> in MP/MPRSW No.: Business Phone Number: <br /> gJ <br /> c s �.4 34 <br /> PI ber's Address(Str e ,City,State,Zip Code): <br /> -L-7-76 0 3 - S8 <br /> IX. COUNTY/ nEPARTM1tNT USE ONLY <br /> E]Disapproved Perm OncludesGroundwater to sue ssuin g tSi ata Stamps) <br /> roved 2f it �� ndudergefee) <br /> � &// / 1 4 <br /> ❑Owner Given Ini i <br /> Adverse Determination 6&_' <br /> X. CONDITIONS OF APPROVAL/ REASONS FOR DISAPPROVAL. <br /> SHU-6398(K.05/94) DISTRIBUTION Original to County,One copy To: Safety 8 Buildings Diuenon,owner,Plumber <br />