Laserfiche WebLink
&111 <br /> Als�oqsin <br /> Safety nd B6�'Division <br /> SANITARY PERMIT APPLICATION 201 W.Washington Avenue <br /> P O Box 7302 <br /> Department of Commerce In accord with Comm 83.05,Wis.Adm.Code Madison,WI 53707-7302 <br /> • Attach complete plans(to the county copy only)for the system,on paper not less County <br /> than 81/2 x 11 inches in size. <br /> • See reverse side for instructions for completing this application State SanitPerm t Number <br /> S E 4 S (� <br /> Personal information you provide may be used for secondary purposes E]Check it revision to revious application 1 f' <br /> [Privacy Law,s. 15.04(1)(m)]- State Plan I.D.Number V <br /> 00 <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INF RMATION <br /> Property Owner Name Property Location <br /> ST a Am Ivot4 1/4 1/4,S T N, RTS E(o <br /> Property Owner's Mailing Address Lot Numberp Block Number <br /> q oS IZVM oo 01' <br /> City,State Zip Code rPtone Number Subdivision Name or CSM Number <br /> MFLS nl. (4Mab -GS= <br /> II. ILDING: (check one) [:] State Owned it <br /> � Nearest Road <br /> vilPublic 1 or 2 FamilyDwelling-No.of bedrooms <br /> 3 K Town OF <br /> III. BUILDING USE: (If building type is public,check all that apply) Parcel TaxNumber(s) I� <br /> 1 ❑ Apartment/Condo �I�—q'v I— Of <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 ❑ Mobi[e 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. V New 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an <br /> System _ System ------------- Tank Only ............. Existing System ________ Exlstlncl5ystem <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 QQseepage 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. Fina[ Grade <br /> Re uired(sq.ft.) Pro osed(sq.ft.) (Ga[s/day/sq.ft.) (Min./inch) Elevation <br /> L}sD 3 �¢ l ,�/ q4,S Feet 7.3 Feet <br /> Capacity VII. FORMATION in gallons Total of <br /> Tanks Concrete site Fiber- Plastic Appr. <br /> Manufacturer's Name con- steel <br /> New Existin structed <br /> Tanks Tanks <br /> Septic Tank or Holding TankInno 100o11✓ ❑ ❑ ❑ 11 <br /> Lift Pump Tank/Siphon Chamber ❑ 1:1 1 D ❑ <br /> VIII. RESPONSIBILITY STATEMENT <br /> [,the undersigned,assume responsibility for installation of the onsite sewage system shown on the attached plans. <br /> Plumber's Name:(Print) Plumber's Signature( tamps) MP/MPRSW No.: Business Phone Number: <br /> c 45 SSS) 7 S- 1$ <br /> Plumber's Address(Street,City,State,Zip Code): <br /> 1 <br /> IX. COUNTY/ DEPARTMENT USE ONLY <br /> ❑Disapproved S itary Permit Fee (includes Groundwater fatessue Issuing Agent ig ture o Ste <br /> roved Sul barge Fee) <br /> 67 <br /> p ❑Owner Given Initial <br /> Adverse Determination '� <br /> X. CONDITIONS OF APPROVAL/REASONS FORD OVAL: <br /> SBD-6398(R.4/99) DISTRIBUTION: Original to County.One copy To: Safety 8 Buildings Division,Owner,Plumber <br />