Laserfiche WebLink
\ scon5In Safety and Buildings Division <br /> SANITARY PERMIT APPLICATION 201 W.Washington Avenue <br /> Dep! In accord with Comm-83.05,Wla.Adm.Code P 0 Box 7302 <br /> Madison,WI 53707-7302 <br /> • Attach complete plans(to the county copy only)for the system,on paper not less County <br /> than 8i/2x11 inches insize. Ettn0 00 -02-42. <br /> • See reverse side for instructions for completing this application State Sanitary Permit Number <br /> 31P17 — 0 <br /> Personal information you provide may be used for secondary purposes ❑Check it revision to previous application <br /> (Privacy Law,s. 15.04(1)(m)]. State Plan I.D.Number <br /> I. APPLICATION INFORMATION-PLEASE PRINT ALL INFORMATION • <br /> Property Owner Name Property Location <br /> ' U1 Sw1/4 Sw 1/4,S Ito T to ,N, RIO E(8 ^N <br /> Property Owner's Mailing Address Lot Number b Block Number <br /> 2 37 l Kee,k,ah 14 — <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> 14-4C-Far(0W1C1 4 WI 53555 ( )83r8-Lo-f32 CSM 403 <br /> II. TYPE OF BUILDING: (check one) ❑ State Owned „ 0 cit <br /> p Villay ge Nearest Road <br /> ❑ Public g 1 or 2 Family Dwelling-No.of bedrooms ..5yrown OF DaI^Y1 keel')CIA Rd. <br /> III. BUILDING USE: (If building type is public,check all that apply) Parcel Tax Number(s) <br /> 1 ❑ Apartment/Condo I.4-0(0(0- (103- ' o~Z <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. Ereplacement • 3, ❑ Replacement of 4• ❑ Reconne �f f,, 5• ❑ Repair of an <br /> System System Tank Only Exist ,,1; .'si Existing System <br /> B) ❑ A Sanitary Permit was previously issued. Permit Number Date_ Issued <br /> V. TYPE OF SYSTEM: (Check only one) �` 'l :.r•: <br /> Non-Pressurized Distribution Pressurized Distribution Exp •ment a� <br /> ane eo�nty EnvlrOtl <br /> 11 ❑Seepage Bed 21 ❑Mound 30 DSpe <br /> �¢6 Department Holding Tank <br /> 12 Q'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. Final Grade • <br /> 450 Required(sq.ft.) Proposed(sq.ft.) (Gals/day/sq.ft.) (Min./inch) Elevation <br /> 5c0 •(o (•5-1O.4 Feet ' 5•6- Feet <br /> er.TANK Capacity <br /> VII. INFORMATION in gallons Total #of Manufacturer's Name Prefab. Site Fiber- Ex <br /> New Existing Gallons Tanks Concrete structed Steel glass Plastic AFP <br /> Tanks Tanks <br /> Septic Tank or+tvfdfrt[Jrank /CDC /GO0 / c/leasato—.. El 0 0 0 0 <br /> Lift Pump Tank/Siphon Chamber 0 0 0 0 0 0 <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) Plumber's Signature:(No Stamps) MP/MPRSW No.: Business Phone Number: <br /> Awtrew Pte'i Kind 4- --,f,-,ol----4). MA2s 2.2OItP5 83i.6(03 <br /> Plumber' Address(Street,City,State,Zip Code): <br /> 47807 k41Ay-k Wauv■titee, t 3 9ct7 <br /> IX. COUNTY/DEPARTMENT USE ON_LY <br /> ❑Disapproved Sanitary pAmit Fee (Ind„desGroundwater D Issued Is gent Sic }� Stamps) <br /> roved Surcharge fee) <br /> pp ❑Adverse Determination 2.40(— 3 I,c o L sl '%r/1 B g.7, <br /> w�? <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: .64 Is. yig ftL taw_ rvvv <br /> as(tM44387) 4-440 , <br /> SBD-6398(R.4/99) DISTRIBUTION: Original to County,One copy To:Safety&Buildings Division,Owner,Plumber <br />