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op c <br /> SANITARY PERMIT APPLICATION afeauety of Building ateriSy <br /> Bureau of Building Water Systems <br /> In accord with ILHR 83.05,Wis.Adm_Code 201 L Washington Ave. <br /> 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 8 112 x 11 inches in size- <br /> 0 See reverse side for instructions for completing this application State Sanitarry P!ye�rmit Number <br /> The information you provide may be used by other government agency programs ,` 7/ / <br /> [Privacy Law,s. 15.04(1)(m)). E]Check if revision to previous application <br /> State Plan I.D.Number �l <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION $ 6 <br /> Property Owner Name Property Location G Gff e- <br /> O 1, 1/4 µLJ v4,S T.3,;? N, R/;? E(or)e <br /> Property Owne ' Mailing Addresss Lot Number Block Number <br /> -7,S-3 41. (.J _ <br /> City,StateZip Code Phone Number Subdivision Name or CSM Number <br /> -41 C76) 6R-451 <br /> II: TYPE F B DING: (check one) ❑ State Owned El' y Nearest Road <br /> Public 1 or 2 FamilyDwelling- No.of bedrooms village 1 <br /> Town OF fL�,� Cp, <br /> III. BUILDING USE: (If building type is public,check all that apply) Parcel TaxNumber(s) <br /> 1 ❑ Apartment/Condo Oo 6 a y ® l6 v <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 ❑ New <br /> System 2. p Replacement 3. ❑ Replacement of/ 4. ❑ Reconnection of 5. ❑ Repair of an <br /> Y ________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 Molding 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 S. Perc. Rate .6. System Elev. 7. Final Grade <br /> 7 S� Required (sq. ft.) Proposed(sq.ft.) (Gals/day/sq. ft.) (Min./inch) Elevation <br /> Feet -- Feet <br /> VII. TANK Capacity <br /> INFORMATION in gallons Total #of Prefab. Site Fiber- Exper <br /> Gallons Tanks Manufacturer's Name Con- Plastic p <br /> New ExistingConcrete strutted Steel glass App. <br /> Tanks Tanks <br /> SeptTTOrkorHolding Tank Dot? �OoJ �J 2, ❑ ❑ ❑ ❑ <br /> Lift Pump Tank/Siphon Chamber El E ❑ ❑ <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'sSignature:(No Stamps) MP/MPRSWNo.: Business Phone Number: <br /> 14111A�� 047-1.- <br /> Plumber's Address(Street,City,state,zip Code): <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑Disapproved Sanitary Permit Fee lindudesGroundwater=ateIssuingAgtur ( sta sApproved ❑Owner Given Initial j�"a`geF�) <br /> Adverse Determination Z <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(R.05/94) DISTRIBUTION: Original to County.One copy To: Safety 8 Ruililings Divi ion,Owner,Plumber <br />