Laserfiche WebLink
.xo,_ Safety and Buildings Division <br /> lding Water System <br /> SANITARY PERMIT APPLICATION Bureau of Building <br /> LId�L� 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 8 112 x 11 inches in size. a:7 Q <br /> • See reverse side for instructions for completing this application State sanitary ery l nJptmer <br /> The information you provide may be used by other government agency programs E]Check if revision(UUJtlo(�p�jre(lviou�s77a plication <br /> [Privacy Law,s. 15.04(1)(m)I- State Plan I.D.Number 0a <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION �� <br /> Property Owner Name Property Location <br /> S S r t/a t/a,S y`7p Tya ,N, R /�E(or <br /> Property rie�Maili g Add ressr , Lot Number Block Number <br /> .J47 0 fes,�/ r� 33 s S s-Ktsq - <br /> City,State Zip Code Phone Number Subdivision Name CS Nu b <br /> e AJ X3'30 ((a ) ��-S/8'1 4 l <br /> II. TYPE F BUILDING: (check one) ❑ State Owned vier4- <br /> _0417C& <br /> Nearest Road <br /> Gr ❑ Vd age C <br /> Aj <br /> ❑ Public 1 or 2 FamilyDwelling-No.of bedrooms Town of S o �I- <br /> III. BUILDING USE: (If buildingtype is public,check all that apply) Parcel Tax Number(s) / p <br /> 1 ❑ Apartment/Condo O©pZ . `��?d O O6 / d <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 ❑ New2 5�Replacement 3. F] Replacement of 4. El Reconnection of 5_ ❑ Repair of an <br /> System System Tank Only ----n.------- <br /> -------------y�xfsting System ExistigSystem <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 D(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 /> Required(sq. ft.) Proposed(sq.ft.) (Gals/day/sq.ft.) (Min./inch) Elevation <br /> go, 96 95 Feet 8,3 Feet <br /> VII. TANK Capacity site <br /> in gallons Total #of Manufacturer's Name Prefab. Con- Steel Fiber- Plastic Exp'r <br /> INFORMATION New lon-S n Gallons Tanks Concrete strutted glass App <br /> Tanks Tanks <br /> Septic Tank or Holding Tank ri El El 0 <br /> I ift Pump Tank/Siphon Chamber Q f0 ❑ ❑ <br /> VIII. RESPONSIBILITY STATEMENT <br /> 1,the undersigned,assume responsibility for installation of the onsite sewage system shown on the attached plans. <br /> Plumber's Name:(Print) / Plumber's Signature: oStam s) MP/MPRSWNo.: Business Phone Number: <br /> Plumber's Address(Street,City,Sta)e,Z i p Code): 7� <br /> ,d m si s/ ,-c.� z✓ Z' _-5 7� <br /> IX. COUNTY/ DEPARTMENT USE ONLY <br /> ❑Disapproved Sanitary Permit Feey(Indudei Groundwater a Iss riwCL <br /> ��� Surcharge Fee) �� (711 <br /> Approved no <br /> Owner Given Initial <br /> Adverse Determination <br /> X. CONDITIONS OF APPROVAL/REASONS FO D SAPPROVAL: <br /> SHO 6398(H.OS/94) DISTRIBUTION: original to Cnuriiy.One copy To: Safety&Ruildinyi Divr ion,owner,Plumber <br />