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I `^ nd. Safety and BuildingsDi ision <br /> �. <br /> =Building Building Water Systems <br /> SANITARY PERMIT APPLICATION 201 E Washington Ave. <br /> V7a.nP.O.Box 7969 <br /> In accord with ILHR 83.05,Wis Adm-Code Madison,WI 53707-7969 <br /> • Attach complete plans(to the county copy only)for the system,on paper not less count 9a`1 <br /> than 8 12 x 11 inches in size. State Sanitary mit Nu er v� <br /> • See reverse side for instructions for completing this application <br /> The information you provide may be used by other government agency programs ❑ <br /> Che, r 2 n previou application <br /> . <br /> (Privacy Law,s 15.04(1)(m)] State Plan ID9 <br /> Number <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION5_ 53 <br /> pocation p N, R rE(or)� <br /> Property Owner ame 1/4 1/4,S T�O r <br /> C» © tretpdamter OL Block Number <br /> Property Owner's Mailing Address G, L <br /> //-�! O <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> c �-e w ( > <br /> ❑ Cit Nearest Road <br /> State Owned y �aS� o <br /> II. TYPE F BUILDING: (check one) ❑ o village <br /> ❑ Public 1 or 2 FamilyDwellin - No. of bedrooms Town OF <br /> At SII. BUILDING USE: (If building type Is public,check all that apply) <br /> Parcel Tax Number(s) <br /> ai5� 6 <br /> 1 ❑ Apartment/Condo 10 ❑ Outdoor Recreational Facility <br /> 2 ❑ Assembly Hall 6 ❑ MedicalFacility/Nursing Home 11 Restaurant/Bar/Dining <br /> 3 ❑ Campground 7 ❑ Merchandise:Sales/Repairs 12 ❑❑ Service Station/Car Wash <br /> 4 ❑ Church/School 8 ❑ Mobile Home Park <br /> 5 f-1 Hotel/Motel 9 E] office/Factory 13 ❑ Other: specify <br /> EA) l <br /> OF PERMIT: (Check only one box on line A. Check box on line B, if applicable) Repair of an <br /> New 2.,� Replacement3- ❑ Replacement of q. ❑ Reconnection of 5. ❑ pTankOnl Exls_tin_gSystem ____ExistingSystem <br /> - y---------------- - -System __System ______ Date Issued <br /> A Sanitary Permit was previously issued. Permit Number <br /> . OF SYSTEM: (Check only one) Other <br /> Pressurized Distribution Experimental <br /> Non Pressurized Distribution 41 ❑ Holding Tank <br /> 30❑Specify Type g <br /> 11 ❑Seepage Bed . 21�Mound 42❑Pit Privy <br /> 12 E]Seepage Trench 22❑In Ground Pressure 43❑Vault Privy <br /> 13❑Seepage Pit <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. Pert. Rate 6. System Elev. Elevatio rade <br /> Required (sq.ft-) Proposed(sq.ft.) (Gals/daylsq.ft.) (Mi`/inch) /O/, Feet Feet <br /> as�o Asa i,a <br /> VII. TANK Capacity Total #of Prefab. 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 /> J� <br /> Septic Tank or Holding Tank SQ 7j ❑ <br /> Lift Pump Tank/SiphonChamber <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 Signature:(No mps) MP/MPRSW No.: Business Phone Number: <br /> Plumber's Name:(Prl / / ��� <br /> u ed'� <br /> PlAddress(Street,City,St� Zip Code): a rP <br /> /�S o�l 5- 5 �S' i�� G✓ S' v8" <br /> IX. COUNTY/ DEPARTMENT USE ONLY <br /> Disapproved Sanitary PermitFee (IndudesGroundwater atelsue Issuin9AgentSig. to Stamps) <br /> ❑ pp Surcharge ree) <br /> V—A--p roved ❑Owner Given Initial ��� ( Z <br /> Adverse Determination <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SeD-6398(it.05/94) <br /> DIS iflMUTION'. Original to Counl y,one cupy To: 5afety 8 Buildings Dim;lon,Owner,Plumber <br />