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77'C Cc�� <br /> Safety and Buldings Division <br /> SANITARY PERMIT APPLICATION Bureau of But <br /> iIngWaterSystems <br /> 201 E.Washington Ave. <br /> In accord with ILHR 83.05,Wis-Adm.Code P.O.Box 7969 <br /> Madison,WI 53707-7969 <br /> • Attach complete plans(to the county copy only)for the system,on paper not Less 112Countyrn0 <br /> than 8 1 x 11 inches in size. <br /> • See reverse side for instructions for completing this application State Sanitary Permit Num <br /> The information you provide maybe used by other government agency programs '530347 <br /> [Privacy Law,s. 15.04(1)(m)]. ❑Check d revision to previous application <br /> State Plan I.D.N nlZgr� <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INF ORMATION <br /> Property Owner Name Property Location ` <br /> 10 1 c S� 5- �� CS 6_1L4'_ 1/4,S T 3�— N, R QE(or)p�� <br /> Property Owner's Mailing Address Lot Number <br /> e%b <br /> City,State r Zip Code Phone Number Subdivision Name Num r <br /> II. TYPE OF BUILDING: (check one) [I State Owned ❑ City N!JQ �'/earest Road <br /> Public 1 or 2 FamilyDwelling- No-of bedrooms ❑ village <br /> E] a k n O <br /> 3 Town OF � ¢ � � � � <br /> III. BUILDING USE: (If building type is public,check allthatapply) Parcel Tax Numbers) <br /> J <br /> 1 ❑ Apartment/Condo oZ (, <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. Dq D'New 2. ❑ Replacement 3. E] Replacement of 4. [:] Reconnection of 5. [:] Repair of an <br /> ____ System --------System __ _ Tank Only _ Existing System____ g _yExisting System <br /> B) ❑ A Sanitary Permit was previously issued. Permit Number Date Issued <br /> V. TYPE OF SYSTEM: (Check only one) <br /> Non-Pressurized Distribution Pressurized Distribution Experimental Other <br /> 11 ❑Seepage Bed 21 Mound 30❑Specify Type 41 [:]Holding Tank <br /> 12❑Seepage Trench 22❑In-Ground Pressure 42❑Pit Privy <br /> 13❑Seepage Pit 43❑Vault Privy <br /> 14171 System-In-Fill <br /> VI. ABSORPTION SYSTEM INFORMATION: <br /> 1. Gallons Per Day 2. Abspi 3. Absorp.Area 4. Loading Rate 5. Perc. Rate 6. System Elev. 7. Final Grade <br /> Required (s t.) Prop�e�(sq.ft.) (Galslday/sq. ft.) (Min./inch) ���� Elev do <br /> cit JJ / O� <br /> eet et <br /> Ca alio <br /> VII. TANK in g Ilo 5 Total #of Prefab Site Fiber- Exper <br /> INFORMATION New Existin Gallons Tanks Manufacturer's Name concrete con- Steel glass Plastic App <br /> strutted <br /> Tanks Tanks <br /> Septic Tank or Holding Tank w ! �� El 0 0 ❑ 0 <br /> Lift Pump Tank/Siphon Chamber BO 3' Ej ❑ Ej El ❑ <br /> VIII. RESPONSIBILITY STATEMENT <br /> 1,the undersigned,assume responsibility for installation of the onsite sewage system shown on the attached plans. <br /> Plumber's Name:(Print) P ber's ignature No Stamp <br /> TPRSW No.: Business Phone Number: <br /> Plumber's Address(Street,City-,State,Zip Code): <br /> IX. COUNTY/ DEPARTMENT USE ONLY <br /> ❑Disapproved Sanitary Permit Fee (includeseroundwder Date Issued Issuing Ageprt Sig atur ( St mps) <br /> Approved ❑Owner Given Initial � surcnar9e ree) <br /> Adverse Determination p�© ' � w'/ <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SHL)-6398(H.05/94) DISTRIBUTIONS 069inal to County,one copy To: safety&Ruildirvy Divnion,Owner.Plumber <br />