DCPZP-1998-01299 - Laserfiche WebLink

Home Browse Search

•/�/� SANITARY PERMIT APPLICATION and wi' COnsin P.O.Box 7969 Department of Commerce In accord with ILHR 83.05,Wis.Adm.Code Madison,WI 53707-7969 • Attach complete plans(to the county copy only)for the.system,on paper not less County '1 than 8 1/2 x 11 inches in size. DIVE_ _0 iOo • See reverse side for instructions for completing this application State Sanitary Permit Number 3//sa�// The information you provide may be used by other government agency programs ❑Check if revision to prt#vious application (Privacy Law,s. 15.04(1)(m)]. State Plan I.D.Number I. APPLICATION INFORMATION- PLEASE PRINT ALL INFORMATION /3 S bad Property Owner Name Property Location 7Dn.1` B/Yam Pr?e / 56.) 1/4 N6 1/4,S 3 T 7 ,N, R 8 E(er) # Propert i wner's Mailing Address Lot Number / Number Alt- G4 .non /' -et . (Block — City,State Zip Code Phone Number Subdivision Name of€ M- traber /44-01-13c-v1 t Less • 1 S3 7/ 7 (6o5 )097i-904o Pf2A re/e / iIef f 79TES II. TYPE OF BUILDING: (check one) ❑ State Owned ❑City / Nearest Road !� pVillage M/dc'1e.Jo1-1 �i1O/60 Cl/2CL6 ❑ Public 1 or 2 Family Dwelling-No.of bedrooms 1Crown OF HI. BUILDING USE: (If building type is public,check all that apply) Parcel Tax Number(s) /9 -- O "7 b 6?- 057 - (7Lo 5 --SJ 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 Q Other: specify IV. TYPE OF PERMIT: (Check only one box on line A. Check box on line B,if applicable) A) 1. .0 New 2. ❑ Replacement 3_ Q 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 Lie Issued V. TYPE OF SYSTEM: (Check only one) C4 `ii Distribution Pressurized Distribution Experim�al 11/4. Otfr�►O 11 ❑Seepage Bed 21 ❑Mound 30❑Specify�y� r, 1410 Holding Tank 12 Seepage Trench 22❑In-Ground Pressure yectitz ty 42°Pit Privy 13 Seepage Pit thC^t.;t,43❑Vault Privy 14['System-In-Fill --0 0,..„orj 1jA VI. ABSORPTION SYSTEM INFORMATION: -Got "b/ 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) q7. / - Elevation Co v 3 /Z_(2. o /Zoo - v — 95-- 7 Feet 48 a- Feet Capacity _ VII. TANK in lon Total #of r Prefab. Site Fiber- Exper INFORMATION gallons Gallons Tanks Manufacturer's Name Concrete con- Steel glass Plastic App. New Existing structed Tanks Tanks Septic Tank or HDMfiLg-enk /ZDU /Zvo / � lti Co.0 _ ❑ ❑ ❑ ❑ ❑ Lift Pump Tank/S�ber °C)� 9 J. _ F ❑ ❑ ❑ ❑ ❑ VIII. RESPONSIBILITY STATEMENT I,the undersigned,assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber's Name:(Print) Plumber's Signature:(No Stamps) /MPRSW No.: Business Phone Number: Al drew IN, )144n 11-4=47—.' yin4L.r a (() --),Y2ji_j-j) cP-6 I 6 b 6°6- k3i-8)03 Plumber's Address(Street,City,State,Zip Code): Co 8.67 cni-" /c.'4 2,t, / w ti Ic.,- / Lai. 5 - 39 7 IX. COUNTY/DEPARTMENT USE ONLY ❑Disapproved Sanitary Permit Fee (Includes Groundwater ate ssue Issui gent Signature(No Stamps) XAroved Surcharge Fee) `� pp ❑Owner Given Initial �� c� -23-9 Adverse Determination X. CONDITIONS OF APPROVAL/REASON FOR DISAPPROVAL: ......____._..__. DISTRIBUTION: Original to County,One copy To: Safety&Buildings Division,Owner,Plumber