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c72coxp amw <br /> Safety and Bu s Division <br /> 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. ". (20_49/0 <br /> ��0 <br /> • See reverse side for instructions for completing this application State Sanitary Permit Number <br /> 3 ' <br /> The The information you provide may be used by other government agency programs ❑check it revision to previous application <br /> (Privacy Law,s. 15.04(1)(m)]. State Plan I.D.Number <br /> 1. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION <br /> Property Owner Name Property Location <br /> 41 <br /> ° !�X EQ o sit/4 1/4,S /(p T ffd ,N, R/ E(o <br /> Property Owner's Mailing Address off Ke Lot Number Block Number <br /> VG 401/ A~1 <br /> City,Stat Zip Code Phone Number ubdivision Name or CSM Number ° Q <br /> ��it II. TYPE OF BUILDING: (check one) E] State Owned ❑ ity Ne Roa <br /> ublic 1 or 2 FamilyDwelling-No. of bedrooms r Vown OF GO ° <br /> III. EIUILDING USE: (If buildingtypeispublic,checkallthatapply) Parcel TaxNumber(s) <br /> 1 ❑ Apartment/Condo ?—yN —O3' <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 2r Office/ 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. 5'New 2- ❑ 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 /> 11 ❑Seepage Bed 21 ❑Mound 30❑Specify Type 41 KHolding 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 /> Required(sq.ft.) Pro osed(sq.ft.) (Gals/day/sq. ft.) (Min./inch) Elevation <br /> GO, /(p g/ /*O/< Feet Feet <br /> Capact VII• INFORMATION in g llons Total #of prefab Site Fiber- plastic Exper. <br /> Gallons Tanks Manufacturer's Name concrete con- Steel glass App <br /> New Existin strutted <br /> Tanks Tanks ��ll <br /> S tl or Holding Tank QQ QOO / 03 G/4 R1 ❑ ❑ I ❑ ❑ ❑ <br /> I.ifl Pump Tank/Siphon Chamber ❑ ❑ ❑ 1 ❑ ❑ ❑ <br /> VIII. RESPONSIBILITY STATEME <br /> I, s T ity for install ion of the onsite sewage system shown on the attached plans. <br /> Plumb s KING ROAD b s Signatu .(No Stamps) MP/ o : Business Phone Number: <br /> a�S'7 <br /> Plumber's h0l 8SUIft ): <br /> IX. COUNTY/ DEPARTMENT USE ONLY <br /> ❑Disapproved Sanitary Permit Fee (includes Groundwater ate Issue Issuing A ent Signature(No Stamps) <br /> roved Surcharge I eel pp ❑Owner Given Initial � a3 ma4,f� <br /> Adverse Determination <br /> X. CONDITIONS OF APPROVAL/ REASONS FOR DISAPPROVAL: <br /> SND-6398(R.05/94) DISTRIBUTION: Original to eounly.One curly To: Su(ety 8 Buildings Dim--ion,Owner,Plumber <br />