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,-X <br /> Safety and Buildings Division <br /> (E!S) <br /> SANITARY PERMIT APPLICATION Bureau of Building Water System! <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 County <br /> than 8 1f2 x 11 inches in size. 2©e <br /> • See reverse side for instructions for completing this application State Sanitary Pemff i urnbber(� <br /> The information you provide may be used by other government agency programs ❑Check if revislbr+�fo9�Ous`rSpUf ion f�f-- <br /> [Privacy Law,s. 15.04(1)(m)]- State Plan I.D.Number -1— <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION <br /> Property Owner Name Property Location <br /> APP' 1/4 1/4,S 24 T I ,N, R E(or)(& <br /> Property Owner's Mailing Address Lot Nuinber Block Number <br /> 2'7 '+h RV. "�t I5 <br /> City,State Zip Code Phone Number Subdivis n Naor CSM Number <br /> COETE/< W 1 1.54-72-9 ( !S) 2�1-34o 01— <br /> m <br /> 4 1P. ZOO <br /> II. TYPE OF BUILDING: (check one) ❑ State Owned ❑ city Nearest Road r� <br /> ❑ Village sP,• <br /> Public 1 or 2 FamilyDwelling- No.of bedrooms .7 Town of Jw W <br /> iss LL40 M R AI 1/ <br /> III. BUILDING USE: (If building type is public,check all that apply) Parcel TaxNumber(s) <br /> 032 5226 __ , 03 0O0 <br /> 1 ❑ Apartment/Condo <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. ;g New 2- ❑ Replacement 3. ❑ Replacement of 4- ❑ Reconnection of 5. ❑ Repair of an <br /> System System ------------- Tank Only---------------Existing System ______ Existing 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 /> 14❑System-In-Fill <br /> VI. ABSORPTION SYSTEM INFORMATION: <br /> 1. Gallons Per Day 2. Absorp.Area 3. Absorp.Area 4. Loading Rate I 5. Perc. Rate 6. System Elev. 7. Final Grade <br /> 3 O O Requir �(sq.ft.) Propose (sq.ft.) (Gals/day/sq.ft.)( Min./inch) Elevation <br /> P — q6-5 Feet qQ .O Feet <br /> Ca aclt <br /> VII. INFORMATION ingallons Total #of Prefab site Fiber- Exper_ <br /> g Gallons Tanks Manufacturer's Name concrete Con- Steel glass Plastic App <br /> New Existin structed <br /> Tanks Tanks �y <br /> Septic Tank or Holding Tank Soo I K#"o V/ 121 ❑ ❑ ❑ ❑ ❑ <br /> Lift Pump Tank/Siphon Chamber ❑ ❑ <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 /> 1ZHAIZn opwtJs 6 '7rs- gam- 41-0 <br /> PI mber's Address(Street,City,State,Zip Codc,- <br /> Z-1760 Pvi36 WEra.s7rm 'W1 , S4$9,:; <br /> IX. COUNTY/ DEPARTMENT USE ONLY <br /> ❑Disapproved Sanitary Permit Fee (Includes Groundwater Date Issued Issuing Agent Si natur (N ) <br /> Approved In Owner Given Initial surcharge Fee) <br /> Adverse Determination <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(R.05/94) DISTRIBUTION: Original to County,One(opy To: Safety&Buildings Division,Owner,Plumber <br />