DCPZP-1998-02484 - Laserfiche WebLink

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�,�► Safety and Buildings Division `risc®nsin SANITARY PERMIT APPLICATION 201 W.Washington Avenue In accord with ILHR 83.05,Wis.Adm.Code P 0 Box 7302 Defartment of Commerce Madison,WI 53707-7302 • Attach complete plans(to the county copy only)for the system,on paper not less County than 8 iQ x 11 inches in size. ®Qi nP ctg-011(// • See reverse side for instructions for completing this application State Sanitary Permit Number Personal information you provide may be used for secondary purposes �to eqs (Privacy Law,s. 15.04(1)(m)). ❑Check if revision to previous application State Plan I.D.Number I. APPLICATION INFORMATION- PLEASE PRINT ALL INFORMATION Property Owner Name Property Location Seto-10 ei ire 1(e y /Uw 114 5 w 1/4,S / T 3 ,N, R /© E(or)W-_ Property Owner's Mailing Address /fr Lot Number Block Number LI P05— V es d1 /lam i1/41,A- City,State Zip Code Phone Number Subdivision Name or.CSM Num),er t o c!"/C7 r t W.V.- •5 3.5 s ' ( ) 7 5 acre ¢_Gf r'c e- I. PE OF B DING: (check one) ❑ State Owned ❑ Cit� Nearest Road �/ p VII age f ❑ Public f' 1 or 2 Family Dwelling-No.of bedrooms / ii3 Town OF f u*/u n CO S fa,- Sc h col III. BUILDING USE: (If building type is public,check all that apply) Parcel Tax Number(s) 1 ❑ Apartment/Condo ,R�-�Sf --O/3— 8`Se l—2.- 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 IR Other: specify nsi d."61.-c.e, IV. TYPE OF PERMIT: (Check only one box on line A. Check box on line B,if applicable) A) 1. ] New 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ Reconnection of fan System System. Tank Only Existing System II�� i System B) ❑ A Sanitary Permit was previously issued. Permit Number DatNifi a 4 /0.Qq V. TYPE OF SYSTEM: (Check only one) ' °One Cou + t Non-Pressurized Distribution Pressurized Distribution Experimental Health Err,. OnMent+pl m 11 ❑Seepage Bed 21 ❑Mound 30❑Specify Type 41 ❑Holdiin4 Tank 12 2 Seepage Trench 22❑In-Ground Pressure . 42❑Pit Privy 13❑Seepage Pit 43❑Vault Privy 14❑System-In-Fill 3— C / 5)a / 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 Required(sq.ft.) Proposed(sq.ft.) (Gals/day/sq.ft.) (Min./inch) Elevation (,00 . I 2-00 12 00 , S- — q el,,3 Feet jo5`-/O zFeet VII. TANK Capacity INFORMATION in gallons Total #of Manufacturer's Name Prefab. Site Fiber- Plastic Exper. New Existing Gallons Tanks Concrete strutted Steel glass App. Tanks Tanks ....Septicliiik. Holding Tank /6,5-0 )6.5-0 f m PZX e. ® ❑ ❑ ❑ ❑ ❑ Lift Pump Tank/Siphon Chamber ❑ ❑ ❑ ❑ ❑ ❑ VIII. RESPONSIBILITY STATEMENT I,the undersigned,assume responsibility for installation of the onsite sewa• stem shown on the attached plans. Plumber's Name:(Print) Plumber's Signature:(No Stamps) Business Phone Number: KK e it n e 1-11 /71 e° o f ) 4( „,,.n,.z -e_e 2-A Y l Y Y (i.o ) S Y t Plumber's Address(Street,City,State,Zip Code): 5-02 2- 1C O 1 (. 1--(..'0uha k e e (.e ,) Z 5,35”q 7 IX. COUNTY/DEPARTMENT USE ONLY ❑Disapproved Sanitary Permit Fee (Includes Groundwater sate slue• Issuing •,:e • . .re y,•: / Approved ❑ Surcharge Fee) _ 7�f Owner Given Initial ��/ Oo .�; ��_�� Adverse Determination ( . `0„ X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: / .. ..•--. DISTRIBUTION: Orininal to County.One coov To: Safety&Buildings Division.Owner.Plumber