DCPZP-1997-01848 - Laserfiche WebLink

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Safety and Buildings Division ��0��i SANITARY PERMIT APPLICATION Bureau of Building Water Systems 201 E.Washington Ave. In accord with ILHR 83.05,Wis.Adm.Code P.O.Box 7969 Madison,WI 53707-7969 • Attach complete plans(to the county copy only)for the system,on paper not less. County than 8 1/2 x 11 inches in size. %,o./>w q 7-O 3 AP • See reverse side for instructions for completing this application State Sanitary Permit Number The information you provide may be used by other government agency programs ❑Check it revision to previous application (Privacy Law,s. 15.04(1)(m)I. State Plan I.D.Number • I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION / 4 7 ''° Property Ownpr Name Property Location S F f ,'.0- Z.I G'- & N,11/4 s„A/1/4,S /9 T 8 ,N,R/2_E(o4.W Property Owner's Mailing Address Lot Number 'Block Number Z-2-3- .�E/"44F-4-- 4f4,-.0.. 3 City,State Zip Code Phone Number Subdivision Name or CSM Number 7'�set ,B .4✓t..L D.,,-, l.e./ S°3 Pi 6 ( eks/07 '3 v9 Cs•"t II. TYPE OF BUILIING: (check one) ❑ State Owned ❑ City • ❑ Public 15+1 or 2 Family Dwelling- No.of bedrooms - ° own OF /1 1NearestRoad 77e.irc-,r .' . Ill. BUILDING USE: (If building type is public,check all that apply) Parcel Tax Number(s) re - 0811 - 15'3- 8 5" 10 — yt 1 ❑ Apartment/Condo 2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility 3 ❑ Campground 7 ❑ Merchandise: Sales/Repairs 11 ❑ Restaurant/Bar/Dining 4 ❑ Church/School 8 ❑ Mobile Home Park 12 ❑ Service Station/Car Wash 5 ❑ Hotel/Motel 9 ❑ Office/Factory 13 ❑ Other: specify IV. TYPE OF PERMIT: (Check only one box on line A. Check box on line B,if applicable) A) 1.14-New 2. ❑ Replacement 3. ❑ Replacement of - 4. ❑ Reconnection of 5_ ❑ Repair of an System System Tank Only Existing System Existing System - B) ❑ A Sanitary Permit was previously issued. Permit Number - R V. TYPE OF SYSTEM: (Check only one) Non-Pressurized Distribution Pressurized Distribution Experimental JUL 1 7 19 er 11 ❑Seepage Bed 21 ❑Mound 30❑Speld T a 41 ❑Holding Tank 12'9Seepage Trench 22❑In-Ground Pressure H� pe rlVlroa riPr 13['Seepage Pit PorttettlEiVauIt Privy 14❑System-In-Fill VI. ABSORPTION SYSTEM INFORMATION: 1.Gallons Per Day 2. Absorp.Area 3. Absorp.Area 4. Loading Rate 5.Perc. Rate 6. System Elev. 7. Final Grade y r . Required(sq.ft.) Proposed(sq.ft.) (Gals/day/sq,ft.) (Min./inch) /,„.r.9s0-0 Ql t,� O. .,( Elevation �/ / , ltxf•/42F e et VII. TANK Capacity gallons Total #of Prefab. Site Fiber- Exper. INFORMATION g Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic APP New Existing structed Tanks Tanks CA-CST:- 151/ Septic Tank or Holding Tank /W17 /000 / 0 0 0 0 0 Lift Pump Tank/Siphon Chamber_ &per 600 • _ 1 'r 'g ❑ ❑ 0 0 0 VIII. RESPONSIBILITY STATEMENT I,the undersigned,assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber's Name:(Print) r/ Plumber' i nature:(No Stamps) I1 / No.: Business Phone Number: Plumber's Address(Street,City,State,Zip Code): peso So oak o K•.. AL ,S 1 4 s-,75"7'9 IX. COUNTY/DEPARTMENT USE ONLY ❑Disapproved Sanitary Permit Fee (Includes Groundwater Da e Issued Iss�f ,—n igna % o Stamps) Surcharge Fee) 7 J 9r14 4 354pproved ❑Owner Given Initial ,i (D �/ // •-, w' pac.Adverse Determination ,�SD 7 `r/ , X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: