HomeMy WebLinkAbout032-540-22-5201-LUP-1997-589SANITARY PERMIT APPLICATION
In accord with ILHR 83.05, Wis. Adm. Lode
Safety and Buildings Division
Bureau a[ Li"Iding Water Systems
201 E Washington Ave.
P.O. Box 7969
Madison, WI 53707-7969
• Attach complete plans (to the county copy only) for the system, on paper riot less
County
than 8 112 x 11 inches in size.
State Sanitary Per it Number
• See reverse side for instructions for completing this application
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)].
State Plan I.D. Number
I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION
Prop wne Name
Property Location
1/4 1/4, S �,A T �f�Q , N, R 5-kor) W
Pro y ner's ailingA4dress
``��ILJJ��
Lot Number 9
Block Number
iL K E, �- Yt
f�
City, State t\ —f—
Zip Cod �/�7
Phone Wam
Subdivision Name or CSM Number
VI) 1. A �G lc.s
Gl.�
( r✓i )� Zz7
11. TYPE OF BUILDING: (check one) ❑ State Owned
ity
❑ Village j, r
Nearest Road
❑ Public 1 or 2 Family Dwelling - No. of bedrooms
Town OF W N eFrd
III. BUILDING USE: (If building type is public, check all that apply) Pa rice] Tax Number(s)
syo
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. ❑ 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 Date Issued
V. TYPE OF SYSTEM: (Check only one)
Non -Pressurized Distribution Pressurized Distribution Experimental Other
11 ❑ Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank
12 ❑ Seepage Trench 22 ❑ In -Ground Pressure 42'0 Pit Privy
13 ❑ Seepage Pit _ — 43 ❑ Vault Privy
14 ❑ System -In -Fill
VI. ABSORPTION SYSTEM INFORMATION:
1. Gallons Per Day 2. Absorp. Area 3. Absorp. Area 4. Loading Rate 5. Pert. Rate 6. System Elev. 7. Final Grade
Required (sq. ft.) Proposed (sq. ft.) (Gals/day/sq. ft.) (Min./inch) Elevation
Feet Feet
VII. TANK
INFORMATION
Capacity
in gallo s
Total
Gallons
# of
Tanks
Manufacturer's Name
Prefab
Concrete
Site
Con-
Steel
Fiber
glass
Plastic
Exper.
App
New
Existingstrutted
Tanks
Tanks
Septic Tank or Holding Tank
❑
❑
❑
❑
❑
❑
Lift Pump Tank /Siphon Chamber
❑
❑
❑
❑
❑
❑
VII[. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility I stalla ' n o e onsite sewage system shown on the attached plans.
S Nanne: yrtnt) 0W Nei
yt, r t KCY'
Business Phone Number:
Pfrmrbet's Address (Street, City, S tee. Zip C ' r�r
0 'er' Ise �
IX. COUNTY / DEPARTMENT USE ONLY
❑ Disapproved
Sanitary Permit Fee (irtcludesGroundwater Date issued
Issuing Agent Signature (No Stamps)
Approved
❑ pp
❑Owner Given Initial
Surcharge Fee)
Adverse Determination
X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL: 1