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Safety and Buildings Division <br /> ^�- Bureau of Building Water Systems <br /> SANITARY PERMIT APPLICATION 201 E.Washington Ave. <br /> In accord with(LHR 83.05,Wis.Adm.Code P.O.Box 7969Madison,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 1 1 inches in size. State Sanitary ermitNu ber (Q I <br /> • See reverse side for instructions for completing this application <br /> The information you provide maybe used by other government agency programs ❑ <br /> Check i(revision to previous application <br /> (Privacy Law,s. 15.04(1)(m)]. State Plan I.D.Number <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION C V <br /> PropeLo ation p <br /> Prtroperty Owner Name 1/4,5 1 T ,N, R 6E(or)W <br /> NOD <br /> Property Owner's Mailing A dress Lot Number Block Number <br /> S C Lo �— <br /> Cit ,Sta e Z Code ( one;umberoff <br /> Subdivisl dame or CS Nu ber <br /> Q ILL.- g L• ' Nearest Road p <br /> 111 PE F BU LDING: (check one) ❑ State Owned ° vu a e G N!\I <br /> Public 1 or 2 FamilyDwelling-No.of bedrooms 3 Town OF Sk#�S <br /> III. BUILDING USE: (If building type is public,check all that apply) Parcel Tax Number(s) <br /> �lq 65 <br /> r703 <br /> 1 ❑ Apartment/Condo 10 ❑ Outdoor Recreational Facility <br /> 2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home <br /> E] Campground 11 RestaurantBar/Dining <br /> 3 <br /> 7 ❑ Merchandise:Sales/Repairs 12 Restaurant/ <br /> Station/Car Wash <br /> 4 ❑ Church/School 8 ❑ Mobile Home Park ❑ <br /> 5 El Hotel/Motel <br /> 9 E] Off ice/Factory 13 Other: specify <br /> IV. TYPE OF PERMIT: (Check only one box on line A. Check box on line B,if applicable) Repair of an <br /> Replacement of 4- ❑ Reconnection of 5. ❑ P . <br /> A) 1. New 2 Replacement 3. ❑ p Existin System __ Existing System <br /> ❑ <br /> System System -------------Tank Only------------------- 9------------------------------ <br /> - <br /> - --- <br /> -y--------------- - <br /> Date Issued <br /> B) ❑ A Sanitary Permit was previously issued. Permit Number <br /> V. TYPE OF SYSTEM: (Check only one) <br /> Experimental <br /> Other <br /> Non-Pressurized Distribution Pressurized Distribution p <br /> 11Seepage Bed 21 ❑Mound 30 C-]Specify Type 41 ❑Holding Tank <br /> 22 In-Ground Pure 42❑Pit Privy <br /> 12 Seepage Trench ❑ Pressure 43❑Vault Privy <br /> 13❑Seepage Pit <br /> 14❑System-In-Fill <br /> VI. ABSORPTION SYSTEM INFORMATION: 7. Final <br /> 1. Gallons Per Day 2. Absorp.Area 3. Absorp.Area 4. Loading Rate 5.Perc. Rate 6. System Elev. E evatignrade <br /> Re fired(sq.ft.) Propose (sq.ft.) (Gal ay/sq.ft.) (Min./int -17 , Feet (0 Feet <br /> VII. TANK Capacity Total #Of Prefab <br /> Site Fiber- plastic Exper <br /> in gallons Manufacturer's Name Concrete Con Steel glass APP <br /> INFORMATION New Existin Gallons Tanks strutted <br /> Tanks Tanks <br /> Septic Tank or Holding Tank ❑ EJ Ej <br /> Lift Pump Tank/Siphon Chamber <br /> [VIII. RESPONSIBILITY STATEMENT <br /> I,the undersigned,assume responsibility for installation of the onsite sewage system shown on the attached plans. <br /> MP/MPRSW No : Business Phone Nu ber: <br /> Plumber's Name:(Prin ) Ptumber'sSignature'(N tamps) 6 <br /> Plum lr's Address(Street,City,State,Zip Co ): Owl- <br /> !X6 <br /> l <br /> IX, COUNTY/DEPARTMENT SE NLY W i <br /> Sanitar Per it F,,,,��(I1��dudes Groundwater ate slue ��11 Issuing Age tSi ata N amps) <br /> ❑Disapproved © 1✓y(� rcharge Fee) R <br /> Approved ❑Owner Given Initial ✓/ , 111 (0 vl - <br /> Adverse Determination <br /> X. CONDITIONS OF APPROVAL/REASON FOR ISAPPROVAL: <br /> SBD-6398(R.05/94) DISTRIBUTION: Original to County,One copy To: safety&BuilUings Division,Owner,Plumber <br />