Laserfiche WebLink
� c6 <br /> Safety and Buildings Division <br /> SANITARY PERMIT APPLICATION 201 E.Washington Ave. <br /> Aksconsin In accord with ILHR 83.05,Wis.Adm.Code P.O.Box 7969 <br /> Department of Commerce 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. <br /> • See reverse side for instructions for completing this application State Sanitary Permit Nu ber <br /> The information you provide may be used by other government agency programs ❑Cft�f Wtorevious application <br /> lPrivacy Law,s. 15.04(1)(m)]. State Plan LD. ber <br /> 1. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION <br /> Property Onen N�3me Property Location <br /> - ,C�-Q- ,J 1/4 1/4,S T yo IN, R16 E(or W <br /> Property Own is Mailing Ad rens Lot Number Block Number <br /> City,State Zip CodePhone Number Subdivisio Name or CSM Number <br /> iC) r <br /> II.'TYPE OF BUILDING: (check one) C] State Owned ❑ ill / Nearest Road 1/19 <br /> Public 1 or 2 FamilyDwelling-No.of bedrooms r Town of /� ���/ Arcl v <br /> 111. BUILDING USE: (If building type is public,check all that apply) Parcel TaxNumber(s) <br /> 1 ❑ Apartment/Condo 03Q J 01 1ST' b 3 —qUD <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. 0 Replacement ' 3. ❑ Replacement of 4. ❑ 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 pLSeepage 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 S. Perc. Rate 6. System Elev. 7. Final Grade <br /> Required(sq.ft.) Proposed(sq.ft.) (Gals/day/sq.ft.) (Min./inch) �� Elevation <br /> 7 Zy3 7 Feet 97 Feet <br /> TANK Capaclt <br /> VII. INFORMATION in allons Total #of Manufacturer's Name Prefab. core steel Fiber- Plastic Exper_ <br /> New Existin Gallons Tanks Concrete strutted glass App. <br /> Tanks Tanks / / <br /> Septic Tank or Holding Tank �6 ! �d d _j/�/9Lc/ ❑ ❑ ❑ ❑ ❑ <br /> Lift Pump Tank/Siphon Chamber I ❑ ❑ ❑ ❑ ❑ ❑ <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)p I Plumber's Signature: No Stamps) MP/MPRSW No-: Business Phone Number: <br /> Plumber's Ar dress(Street,City,State,Zip Code),: <br /> o X -.S-/ _f </ ' <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑Disapproved Sanitary Permit Fee (Includes Groundwater Date Issued Issuing a Signa re(N Sta ps) <br /> pproved ❑Owner Given Initial 1,5-(g � surcharge Fee) `/1 �q <br /> �\ Adverse Determination ` /&�'" <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6396(R.11/96) DISTRIBUTION: Original to County.One copy To: Safety&Buildings Division,Owner,plumber <br />