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Safety and Buildings 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.0-Box 7969 <br /> Madison,WI 53707-7969 <br /> Attach complete plans(to the county copy only)for the system,on paper not less Cou <br /> than 8 1/2 x 11 inches in size. <br /> See reverse side for instructions for completing this application State Sanitary Permit Nu``�mb' <br /> The information you provide may be used by other government agency programs E]Check it revision prev us <br /> plication <br /> [Privacy Law,s- 15.04(1)(m)]. State Plan I.D.IN UM <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION N//fl[1— <br /> Property Owner Name f Property Location <br /> TO �/S s/21/a 1/4,5 3p T yO ,N, R 9�E(o W <br /> PropeOwner's Mailing Address Block Number <br /> k C t ,State Zip Code Phone Number Subdivision Name or CSM Number <br /> 44k4, sy (215")a3y i <br /> II. TYPE OF BUILDING: (check one) ❑ State Owned ❑ city Neares Road �r" <br /> OZ E] Village SC O <br /> Public 1 or 2 FamilyDwelling-No.of bedrooms Town OF D/ L K• 130 <br /> III. BUILDING USE: (If building type is public,check all that apply) Parcel TaxNumber(s) <br /> 1 F Apartment/Condo 0 -2 IF411 b " a / U <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, Di Replacement 3. E] Replacementof 4- E] Reconnectionof 5- E] 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 gLSeepage 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 /> Required(sq. ft.) Proposed(sq. ft.) (Gals/day/sq.ft.) (MinAnch) Elevation <br /> Feet 1 Feet <br /> Capact <br /> VII. INFORMATION in Allo s Total #of Prefab Site Fiber- Exper <br /> g Gallons Tanks Manufacturer's Name Concrete Con- steel glass Plastic App <br /> New Existin strutted <br /> Tanks Tanks C <br /> Septic Tank or Holding Tank bpd gooC) J ❑ ❑ ❑ ❑ ❑ <br /> Lift Pump Tank/Siphon Chamber ❑ ❑ ❑ ❑ ❑ ❑ <br /> VI11. 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 /> �✓ �� ��s��/ �� �c� �yam-���� <br /> Plumber's Address(Street,City,state,Zip Code): <br /> S ,. 4,/ <br /> ye- <br /> IX. COUNTY/ DEPARTMENT USE ONLY <br /> Disapproved 5anitar /Permit Fee ( dudergeIee) er ate Issue Issuing a Signa re o mps) <br /> �V O urcharge fee) <br /> pproved ❑Owner Given Initial <br /> i <br /> Adverse Determination <br /> X. CONDITIONS OF APPROVAL/ REASONS FOR DISAPPROVAL: <br /> SRU-639B(x.05/94) DISTRIBUTION-. original to Courts.One copy To: safety&Buildings Div,,on,Owner,Plumber <br />