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Safety and Buildings ivmo)n <br /> SANITARY PERMIT APPLICATION Bureau of Building Water System <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 112x 11 inches in size. E 6 <br /> • See reverse side for instructions for completing this application State Sanitary Permit <br /> (�N((u�;mb/e-�o <br /> The information you provide may be used by other government agency programs � to io / 1 <br /> (Privacy Law,s. 15.04(1)(m)]. ❑Check it re ion previous application <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMN <br /> ATIOState Plan I.D.Number j } <br /> Property Owner Name Irl/ $ f•�/ /f <br /> p� Property Location IU/ <br /> 1/4 1/4,S 7 T 4D E(or W <br /> Property Owner's Mailing Address <br /> n Lot Number <br /> a.+l r d <br /> Cit ,Stat Zi Cod � ��h'1 •�.. <br /> Phone Num er Subdivisi n Name or CSM Nu er _ ' <br /> l . ( 9. �S <br /> II. TYPE OF B I DING: (check one) ❑ State Owned ❑ ity <br /> El Public 1 or 2 FamilyDwelling- No. of bedrooms 3 ❑ Village Nearest Road <br /> J <br /> Town OF C6� IRLtt .ice• a•. Y'/>rz <br /> 111. BUILDING SE: (If budding type is public,check all that apply) Parcellax Number(s) <br /> 1 ❑ Apartment/Condo 0ZS-g107-03- DOD2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 <br /> 3 El Campground 7 ❑ Merchandise: Sales/Repairs 11 ❑ Outdoor Recreational Facility <br /> 4 ❑ Church/School 8 [-] Mobile Home Park ❑ Restaurant/Bar/Dining <br /> 5 ❑ Hotel/Motel12 ❑ Service Station/Car Wash <br /> 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. ;q New 2. ❑ Replacement <br /> ------System - System - - -3 ❑ RapkOnmentof 4_ E] Reconnection of 5_ E] Repair of an <br /> -- - - Existing System _ stem_ <br /> --------------ExistingSy <br /> stern <br /> B) ❑ A Sanitary Permit was previously issued. Permit Number <br /> Date Issued <br /> V. TYPE OF SYSTEM: (Check only one) <br /> Non Pressurized Distribution Pressurized Distribution <br /> Experimental Other <br /> 1 1Seepage Bed 21 ❑Mound <br /> 12 Seepage Trench 30❑Specify Type 41 ❑Holding Tank <br /> 22❑In-Ground Pressure 42❑Pit Privy <br /> 13❑Seepage Pit <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 E4Feet <br /> nal Grade <br /> Req�ir d (sq. ft.) Propos d(sq.ft.) (Gals/da /s ft. <br /> y q' ) rM,(Min./inch) r 11 / tion <br /> VII. TANK Capacity 7 �p FeetINFORMATION in gallons Total #ofsiteGallons Tanks Manufacturer's Name PrefabNew EXIStin Concrete Con- Steel sticExper <br /> Tanks Tanks strutted gApp <br /> Septic Tank or Holding Tank ❑ ❑ ❑ ❑ <br /> Lift Pump Tank/Siphon Chamber El ElO ❑ <br /> VIII. RESPONSIBILITY STATEMENT El <br /> I,the undersigned,assume responsibility for installation of the onsite sewage system shown on the attached <br /> 2 , <br /> r . ✓CQYp/ vL�planrs:S <br /> .Plumber'sName:(Print) Plumber's MP/MPRSWNo: 8usinessPhoneNum16— gnatur (Ntam s) b <br /> reet,Cmber'sAddress itypCode): .// <br /> 3 <br /> IX. COUNTY/DEPARTMENT/USE ONLY <br /> ❑Disapproved Sam ry Permi (includes Groundwater ate Issu Issuin A f :51 a <br /> pproved rcharye Fee) N tamps) <br /> ❑Owner Given Initial <br /> Adverse Determination <br /> X. CONDITIONS OF APPROVAL/REASONS F R DISAPPROVAL: <br /> SND-6398(R.BS/9a) DISTRIBUTION: Original G)County.One cn r io: Sa/et <br /> f Y y&RuilJinys Dim:mn,Owner,Plumbzr <br />