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Safety and Buildings Division <br /> (E! <br /> �7A SANITARY PERMIT APPLICATION Bureau of Building Water Systems <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 Count <br /> than 8 vi x 11 inches in size. 3T <br /> • See reverse side for instructions for completing this application StateS��ani�nJ{-ii)tarrylPerm/it�Nuu]m�b_er <br /> The information you provide may be used by other government agency programs ❑Checlt-Xrwi1Vt previous application <br /> [Privacy Law,s. 15.04(1)(m)I- State Plan I.D.Number, <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INF ORMATION <br /> For erty Owner Nar , _eroperty Location <br /> i eln.04</S / NE 1/4,5 � g T q� N, R���-(er W <br /> Property Ow er'sM Address Lot Number Block Number <br /> 1b3S ) UAli yrvi, t• It <br /> State I Zip C'Ve Phone Number Subdty Ion Name or CSM Number <br /> a•a u I.c) L .- X30 c7/T6S6=7 �- lv ISS <br /> II. TYPE UILDING: (check one) ❑ State Owned It Nearer Roa <br /> El Village <br /> Public 1 or 2 FamilyDwelling- No.of bedrooms �' Town OF SC.t1lSS E `������'^^""T4 <br /> III. BUILDIN USE: (If building type is public,check all that apply) Parcel TaxNumber(s) p <br /> 1F Apartment/Condo O 3 AWU O <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 2. LIQ Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5- ❑ Repair of an <br /> System _System ------------- Tank Only _ ________ Existing System _____ _ExistingSystem <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 /> 1 1XSeepage 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 5. Perc. Rate 6. System Elev. 7. Final Grade <br /> 3�a Regyi2re'd (sq. ft.) Proposedd((sq.ft.) (Gals/day/sq. ft.) (Min./inch) Elevation <br /> (1..�f ((�� , o k)• Feet t o r SFeet <br /> VII. TANK Capacity site <br /> in gallons Total #of Manufacturer's Name prefab. Con- Steel Fiber- plastic Exper. <br /> INFORMATION New Existin Gallons Tanks Concrete strutted glass App. <br /> Tanks Tanks �rnj� III,I, <br /> _E1 El <br /> e tic T or Holding Tank 7 J✓ W(,e�)' <br /> Lift Pump Tank/Siphon Chamber ❑ El ❑ ❑ F <br /> VIII. RESPONSIBILITY STATEMENT <br /> I,the undersigned,assume responsibi ity for installation of the onsite sewage system shown on the attached plans. <br /> Pu bet's Na Print) Plu ber'sSignatur tamps) MP/MPRSW No.: Business Phone Number: <br /> �S r Y_ �- <br /> Plumber's Ad rens(Street,Cty,State, Code): ( <br /> 7 (/vl 1 <br /> IX. COUNTY/ DEPARTMEN USE ONLY <br /> ❑Disapproved Sani ry Permit Fee (Includes Groundwater ate I ue Issuing Agen ignature(N ps) <br /> S Surchargelet,) <br /> /� lf� <br /> proved ❑Owner Given Initial a � z <br /> Adverse Determination � <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SHO-6398(R.05/94) DISTRIBUTION: original to County.One copy To: safety 8 Buildings Divi wn,Owner,Plwnter <br />