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SANITARY PERMIT APPLICATION Bureau of BuildingWaterDivision <br /> Systems <br /> In accord with(LHR 83.05,Wis.Adm.Code 201 E.Washington Ave. <br /> P.O-Box 7969 <br /> • Attach complete plans(to the county copy only)for the system,on paper not less County Madison,WI 53707-7969 <br /> than 8 112 x 11 inches in size- <br /> See <br /> • See reverse side for instructions for completing this application State Sanitary Permit Number <br /> 3 F <br /> The information you provide may be used by other government agency programs si �� <br /> (Privacy Law,s. 1 5.04(1)(m)]. ❑Check if revision to previous application <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION State Plan I.DI.D.Nurnmber— <br /> Proerty Owner Name <br /> DAVE <br /> Property Location <br /> G L- 1/4 1/4,S T 40 ,Nr R E(or W <br /> Property Owner's Mailing Address Lot Number <br /> City,State rZ�ipode Phone Number Subdi iion Name1 Seo ( 20 C 5 3 <br /> II. TYPE OF BUILDING: (check one) ❑ State Owned 3 ❑ it age <br /> Nearest Road <br /> Public 1 or 2 FamilyDwellin -No. of bedrooms ❑ Village <br /> Town OF S4(_0 Oe RD. <br /> III. BUILDINGUSE: (If building type is public,check all that apply) Parcel TaxNumber(s) (� ! / <br /> 1 [:] Apartment/Condo a�_B — 1 /� I �q (/7 ;?-c) <br /> 2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility <br /> 3 E] Campground 7 E] Merchandise: Sales/Re airs <br /> 4 P 11 ❑ Restaurant/Bar/Dining <br /> ❑ Church/School 8 ❑ Mobile Home Park <br /> 5 E] Hotel/Motel 9 ElOffice/Factor 12 Service Station/Car Wash <br /> Y 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 System - -2. ❑ System <br /> 3. ❑ Replacement of q ❑ Reconnection of 5 Repair of an <br /> ---- -__Y__ ---- y ------ Tank Only-- --- -- -- - Existing System ❑ ExistingSystem <br /> --------------- -y---- <br /> B) ❑ A Sanitary Permit was previous) issued. Permit Number Date Issued <br /> V. TYPE OF SYSTEM: (Check only one) <br /> Non-Pressurized Distribution Pressurized Distribution Experimental Other <br /> 11Seepage Bed 21 El Mound 30 E]Specify Type 41 E]Holding Tank <br /> 12 Seepage Trench 22 p InQ4punqressure <br /> 13❑Seepage Pit 42❑Pit Privy <br /> 14❑System-In-Fill 43❑Vault Privy <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 /> Re <br /> quire (sq.ft.) Proposed(sq.ft.) (Gals/day/sq.ft.) ( in-/inch q Elevation oO • 5 I$ b Feet • S' Feet <br /> VII. TANK Capacity <br /> INFORMATION in gallons Total #of Prefab Site <br /> New ExistingFiber_ Ex Gallons Tanks Manufacturers Name Concrete Con- Steel Plastic per <br /> - <br /> Tanks Tanks <br /> structed glass App <br /> Septic Tank or Holding Tank Q�Q (�(j ❑ ❑ ❑ -❑ ❑ <br /> Lift Pump Tank/Siphon Chamber El ❑ ❑ ❑ ❑ <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 /> ,ICrAIs '{ZG 715. 8b6- S <br /> Plumber's Address(Street, ity,State,Zip Code). <br /> 2-1-16 O w 60-5 g LJI . -94$ji <br /> IX. COUNTY/ DEPA TMENT USE ONLY <br /> ❑Disapproved Sanitary Permit Fee (Includes Groundwater Date sjue / Issuing A e ign a(NQijps) <br /> Approved ❑Owner Given Initial ` Surcharge Fee) <br /> Adverse Determination L/ <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(R.05/94) DISTRIBUTION: original to County,one copy To: Safety&Building,Division,Owner,Plumber <br />