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Safet and Buildin s Division <br /> SANITARY PERMIT APPLICATION Bureau of Building Water Syste <br /> 201 E.Washington Ave. 1 <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 81/z x 11 inches in size. 4�.Oj t.- <br /> ol <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 E]Check if revision to previous application <br /> (Privacy Law,s. 15.04(1)(m)]. <br /> State Plan I.D.Number <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION <br /> Prope yowner Name / Property Location <br /> A0 Q. c��✓�J .T/`. �i4 1/4,S T d ,N, RISE(or� <br /> Property Owner's ling Address Lot Number, Block Number <br /> /Ite <br /> City,e_State Zip Code Phone Number SuWwieienidame or CSM Number �� _ <br /> k015f � 5_ )3 <br /> el J� ( s -2f,6 i C/L <br /> II. TYPE OF BUILDING: (check one v Nearest Road <br /> ❑ State Owned Village �^^f��r <br /> Public 1 or 2 FamilyDwelling- No. of bedrooms 3 own OF ZAC" 5411 J117 <br /> III. BUILDING USE: (if building type is public,check all that apply) Parcel Tax Numb'er((s) <br /> 1 E] Apartment/Condo <br /> )� <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 <br /> 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. A 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 Weepage Trench 22❑In-Ground Pressure a� / 1 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 1 6. System Elev. 7. Final Grade <br /> UsO Required(sq. ft.) Proposed (sq.ft.) (Gals/day/sq. ft.) (Min./inch) Elevation <br /> TT S�s-3 4<00 �7s" — 9S� Feet 77,8 Feet <br /> VII. TANK Capac ty <br /> INFORMATION in gallons Total #of Manufacturer's Name Prefab. Site Fiber- Plastic Exper <br /> New Existin Gallons Tanks Concrete Con- Steel glass App. <br /> strutted <br /> Tanks I Tanks <br /> Septic Tank or Holding Tank 000 d r/ SJ ❑ ❑ n Q El <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 /> Plumber's Name:(Print) Plumber's Signature:(No Stamps) MP/MPRSW No.: Business Phone Number: <br /> GJAa/v_- yf>4d/" <br /> Plumber's Address(Street,City,State,Zip Code): <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑Disapproved Sanitary Permit Fe (Inrlade>Groundwater at sue Issuing t Signa re(N St mps) <br /> KApproved / urcharge Fee)❑Owner Given Initial <br /> Adverse Determination <br /> X. CONDITIONS OF APPROVAL/ REASONS FGFR DISAPPROVAL: <br /> SND-6398(R.05/94) DISTRIROTIONoriginal to enunly,one urpy To: Safety 8 Ruildirvy nivr,ion,Owner,Pomtx <br />