HomeMy WebLinkAbout022-1090-60-000
'r P I b. 60 1/U/V
3,170 PROJECT DETAIL DATA SHEET p 192
L ~/'~'l ~tNG
NAME OF BUSINESS /71 Ci A
LOCATION 144L S r_f _ 1 t ~~G tST C~~CI /X
street or highway city or township county
LEGAL DESCRIPTION
OWNER &),4) Mailing address zip,
ARCHITECT OR ENGINEER Address _
ZIP
PLUMBER Address Joel
~7E' .rL 5 z I PS rl.:t.z
1. Check appropriate building usage(s) and fill in the information requested opposite
each usage listed:
Existing building New building 0,3,11qL' Oll6Z-Addition
If addition to existing building attach detailed memo for each.
( ) Drive in restaurant Car spaces
( ) Restaurant Seating capacity (10 sq. ft./person)
( ) Dining hall Per meal served Toilet waste Yes No
( ) Motel ( ) Hotel ( ) CottaS-s Number of units: 2 persons/unit
4 persons/unit TOTAL NUMBER OF UNITS
( ) Churches Number of persons Kitchen Yes No
i ( ) Bar or cocktail lounge Seating capacity (10 sq. ft./person)
( ) Nursing or rest home Number of beds
( ) Mobile home park Number of units - dependent (camper trailer)
l c ~4LjC - nondependent (mobile home)
( )re Number of employees _
Number of customers sq. ft./person)
( ) Service station Number of cars served (daily)
( ) School Number of classrooms Meals served Yes
No
Shavers provided Yes No
( ) Factory or office building Number of persons (total all shifts
( ) Apartments Number of bedroom
Other Specify j,1~ai
2. Indicate whether or not the following facilities are connected:
Food waste grinder Yes No A_ Dishwasher Yes No x
Automatic clothes washer Yes No Automatic potato peeler Yes
Other . . . (Specify) No
3. Fill in the appropriate information for the following as ''indicated:
- Septic tank capacity planned
Percolation test results - ATTACH PERCOLATION TEST ND SOIL BORINGS REPORT SHEET
COMPLETE OTHER SIDE
Seepage trench bottom area planned width
linear feet depth
Seepage be'd area planned width
linear feet - depth
Seepage .p i t planned 06 o4ti+cfe diameter
depth below inlet 0 dF.pth
4. See approved plan for specifications and details.
Signa pre of person complet'ng form: STATE DIVISION OF HEALTH, PLUMBING SECTION
P. 0. Box 309, Madison, Wisconsin 53%01
Approved. ;f
t
Address: 'C Date JUN 2 9 19Y2
Z I P THIS APPROVAL IS. BASED ON STATE PLUMBING
/ ll CODE REQUIREMENTS AND DOES NOT EXEMPT THE
Date: ly ` 4 7 _ INSTALLATION FROM CITY, VILLAGE, TOWNSHIP
OR COUNTY REGULATIONS OR PERMIT REQUIRE-
MENTS AND SHALL BE VOID IF REVISED WITHOUT
THE WRITTEN APPROVAL OF THE DIVISION OF
HEALTH.
THIS APPROVAL SHALL BE VOID IF
DEPARTMENTAL USE ONLY NOT INSTALLED WITHIN TW
! FROM THE DATE OF O PEARS
MPROVAk
f
040=1102-60-00 y .
-000
x
022-1088-80-000
040-1102-70-002
W - S W_ ~.r a a2
w.
sE - SW
f 022-1088-90-100 022-1088-95100
n,
. hr
A
r Fi
Y n
z
022-1090-60-000
NW - NW
276-!1043-35-106
276-1041-09-000
~76-1043-35-108 NE - NW
022-1090-50-000
35
2 -1043-35-10
36 276-1041-07-000
~di
~76-1043-10-000 76-1041-05-
, s
r
2"6-1043-35-126
,
2 6-1043-35-128
276-1071-30-000 . "
276-1071-50-1 00276-1071-20-000
2 6-1043-35-136 =~0 022-1091-10-000
SE - NE SW - NW SE - NW
134°"`
!16-l 043-35-
276-104 -35-130
1 276-1071-30-100
n 276-1071-40-050
276-1071-40-060
6- 1071-40- 0
2
276-10 -35-138