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SANITARY PERMIT APPLICATION Safety and Buildings Division <br /> Bureau of Building Water Systems <br /> In accord with ILHR 83.05,Wis.Adm.Code 201 E.Washington Ave. <br /> 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. 73acne 81 <br /> 3630 <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 / <br /> [Privacy Laws. 15.04(1)(m)). ❑Check i is pr ap lcallon <br /> State Plan I.D.Num <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION <br /> Property Owner Name �� Property Location Ss Z MW <br /> �! /f-L$ERT —rte 23 T 4 N, R SSE(or W <br /> Property Owner's Mailing Address Lot Number Block Number <br /> C17351116 (24"Mliellr%4 <br /> City,S Zip Code I Phone Number Subdivision Name or CSM Number <br /> CLL 4/1AT, Ad (T ) / <br /> II. TYPE OF BUILDING: (check one) ❑ State Owned oClwy / Nearest Road <br /> Lj Public 1 or 2 FamilyDwelling- No.of bedrooms � on of .41Ar40 .I417-Z 61u' n'I,vizSfF <br /> III. BUILDING USE: (If building type is public,check all that apply) Parcel TaxNumber(s) <br /> 1 ❑ Apartment/Condo 1 014-aaa3^D/-6OD <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. Jul New 2. ❑ Replacement 3. ❑ Replacement of q ❑ Reconnection of 5. ❑ Repair of an <br /> System --------System --- --- Tank Only---------------Existin System ExistingSystem <br /> ----Existing y <br /> - ------------------ - ---- <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 C4 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 /> Required(sq. ft.) Proposed(sq.ft.) (Gals/day/sq. ft.) (Min./inch) / Elevation <br /> G�B 7 Mcr 4. Z Feet <br /> VII. TANK Capacity <br /> ' ,L-�f Feet <br /> INFORMATION in gallons Total #of Manufacturer's Name Prefab Site Fiber- Expe <br /> New Existin Gallons Tanks Concrete Con- Steel glass Plastic APp <br /> Tanks Tanks <br /> strutted <br /> Septic Tank or kSeldn+gfiank /000 � F-1 El El ❑ <br /> LiftPump Tank/Siphon Chamber � ❑ Ej Q ❑ <br /> VIII. RESPONSIBILITY STATEMENT <br /> I,the undersigned,assume responsibi ity for installs n of the onsite sewage s stem shown on the attached plans. <br /> Plumb her' Signatur No Stamps) M P o.: Business Ph one Number: <br /> 24531 KING ROAD <br /> Plumber's LttA €y' ,Qa " <br /> N ): <br /> 17161 469-An2a <br /> IX. COUT / P v USE ONLY <br /> ❑Disapproved SanWy Permit Fee (In"odeseroundwater ate ssued IssuingA en I re( s) <br /> Approved ❑OwnerGivenInitial Al <br /> "ha`gefPe) <br /> Adverse Determination / <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(R.05194) DISTRIBUTION: Original n)(minty,One copy To: Sofety 8 Rnildings Divoion,Owner,Plun,Wr <br />