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oyl Cep f <br /> Safety and Buildings Division <br /> SANITARY PERMIT APPLICATION Bureau Building Water System. <br /> 201 E.Washington Ave. <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 8 12 x 11 inches in size. 131,e./? <br /> e See reverse side for instructions for completing this application State Saniiitt�tarrryy,)Pe it N er <br /> The information you provide may be used by other government agency programs ❑�k i(re isi7 un tO previ us application <br /> [Privacy Law,s. 15.04(1)(m)]. State Plan I.D.Number <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION <br /> Property Owner Namenn s Location <br /> LC. A �YIC leSOs.n o�U4operty1 /4,S T g ,N, R E-tor)W <br /> F�roqsrty Owner's Mailinq Add ss Lot Number Block Number <br /> tIFt <br /> City,State! Zip Code Phone Number Subdivision Name or CSM Number <br /> ,�Sdo LJ4 (71K-) 4 <br /> II. TYPE OFBUILDING: (check one) ❑ State Owned [Ii-it y Nearest Road <br /> ❑ Village r� <br /> Public 1 or 2 Family Dwelling- No.of bedrooms Town OFD stat,I /r1 k 1� <br /> III. BUILDING USE: (If buildingtype ispublic,check allthatapply) Parcel TaxNumber(s) <br /> 1 ❑ Apartment/Condo a 00(V — <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. 1,;f New 2. ❑ Replacement 3. ❑ Replacement of 4_ ❑ Reconnection of 5. ❑ Repair of an <br /> Y_'_'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❑Seepage Trench 422 Zaa.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) q _ Elevation <br /> j� < S % Feet 7, Y� Feet <br /> TANK 2 Ca aclt <br /> VII INFORMATION in gallons Total #ofPrefab. Site Fiber- plastic Fxper <br /> Gallons Tanks Manufacturer's Name Concrete Con- Steel glass App <br /> New Existing strutted <br /> Tanks Tanks <br /> Sep[ic T' k r Holding Tank L J?SP <br /> tPumpTa /Siphon Chamber 7 —y4 ® 1 ❑ F-1 F-1 ❑ 0 <br /> ESPONSIBILITYSTATEMENT CC-,,�a <br /> I,the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. <br /> Plumber's Name:(Pri ) Plu ber's Signatur :( tamps) MP/MPRSW No.: Business Phone Number: <br /> �S e � z2.s-zz .G 6- C) <br /> lur -er's Add�(Street,Ci y,Sta ,Zip Code): // <br /> Ftf `v. 10 ✓ P' �1 ` <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑Disapproved Sanitary Permit Fee (Includes Groundwater Date Issued IsswngAgent natur Nos s) <br /> roved r erge fee) <br /> pp ❑Owner Given Initial <br /> Adverse Determination <br /> X. CONDITIONS OF APPROVAL/REASONS FOR D APPROVAL: Ir <br /> SND-6398(R.05194) DMAIRUTION: Original to Cnunly.One copy To. 5afely&Ruildings Division,Owner,Plwrher <br />