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moma EwaSafety and Buildin s Division <br /> et■c,r.r. 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 County / <br /> than 8 112 x 11 inches in size. 7 <br /> • See reverse side for instructions for completing this application State Sanitary Permit Number <br /> The information you provide may be used by other government agency programs t�$717 <br /> (Privacy Law,s. 15.04(1)(m)]. <br /> ❑C k d wsion to previous application <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INF RMATION I <br /> State Plan I.D.Num e + <br /> j <br /> erty Owner Name Property Location <br /> v4 1fa,S q T3$ ,N, R 5 E(or We y tt <br /> g Address LOFWrw6er Block Number <br /> 40% <br /> City,S ate Zip Code P one Number Subdivision Name or CSM Number <br /> ( ) <br /> II. TYPE-OF BU L ING: (check one) ❑ State Owned ❑ city Ne rest Road <br /> Public 1 or 2 FamilyDwelling-No. of bedrooms �� Iowan of LA (VLLeffC <br /> III. BUILDING USE: (If building type is public,check all that apply) Parcel TaxcN{�umbberr((s)) �.j. <br /> 1 ❑ Apartment/Condo 01D i " ' `Po <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. Z New 2. ❑ Replacement 3. ❑ Replacement of 4, ❑ Reconnection of 5. ❑ 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 Seepage 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 /> L, 300 Re fired(sq. ft.) Pr posed(sq42A .ft.) (Gals/day/sq.ft.) (Min./inch), Elevation <br /> VII. TANK Capac ty /`� Feet ,Q Feet <br /> INFORMATION in gallons Total #of Manufacturer's Name Prefab. Site Fiber_ Exper <br /> New Existin Gallons Tanks Concrete Con- Steel glass Plastic App <br /> Tanks Tanks <br /> strutted <br /> Septic Tank or Holding Tank ...r K El Elift Pump Tank/Siphon Chamber 1:1 ❑ <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 Signator :( Stamps) MP/MSW No.: Business Phone Number: <br /> um er's Address(Street,Ci State,Zip Code—yr <br /> ,,..}} 3L(/� S $ <br /> 11 <br /> 0 S 5rEK W I- <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> E]Disapproved Sanitary Permit Fee (includes Groundwater ate sSueA� Issuing en ignat (No s) <br /> //��PProveU ❑ s arge FPe) <br /> �r J <br /> Owner Given Initial �j� �' <br /> Adverse Determination (J <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(R.05194) DISTRIBUTION: Original to County,One ropy To: Safety 8 Buildings Divi-ion,Owner,Plumber <br />