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F <br /> &G1 C <br /> Safety and Buildln sDivision <br /> SANITARY PERMIT APPLI N f Bureau of Building Water Systems <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 2 Count 02, <br /> than 8 1x 1 1 inches in size. r�T� <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 3a� 3a g <br /> (Privacy Law,s. 15.04(1)(m))_ <br /> 9 Y P 9 ❑check it revision to previous application <br /> State Plan I.D.Number �t <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION r(�1 — <br /> Property Owner Name Property Location �?� <br /> e- o /t9 7 ScJ1/4 /0L4/1/4,S ��, T O r N, R1/ E(or) v`�J <br /> Propert Owner's Mailing Address Lot Number Block Number <br /> C <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> W S V 9 36 ( )Fa 7115- <br /> Ill. TYPE OF BUILDING: (check one) ❑ State Owned ❑ City �1 Nearest Road <br /> Public or 2 Famil Dwellin - No.of bedrooms ❑ rowan OF O/T /� '�� d, ��- C <br /> III. BUILDING USE: (If building type is public,check all that apply) Parcel TaxNumber(s) <br /> 1E Apartment/Condo 0,;z O y3 a s - o <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. rNew 2. ❑ Replacement 3. E] Replacementof 4. E] Reconnectionof 5. [:] Repair of an <br /> -___ ystem __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 9Seepage Bed 21 ❑Mound 30❑Specify Type 41 ❑Holding Tank <br /> 12❑Seepage Trench 22❑In-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 /> ev 0 Required(sq. ft.) Proposed(sq.ft.) (Gals/day/sq. ft.) i <br /> (Min./ nch) 7 Elevation <br /> 4/12s1,3a 6 9 4il' Feet 7 Feet <br /> Capacity <br /> VII. TANK in Ca gallons Total #ofPrefab. Site Fiber- Exper <br /> INFORMATION New Existin Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App <br /> strutted <br /> Tanks Tanks <br /> Septic Tank or Holding Tank 7.50 7:5­0 <br /> Lift Pump Tank/Siphon Chamber Op 0-- El I] ID El <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: Tint) Plumber's Signature: oStamps) MP/MPRSWNo.: Business Phone Number: <br /> Plumber's Address(Street,City.State,Zip Code): <br /> IX. COUNTY/ DEPARTMENT USE ONLY <br /> ❑Disapproved Sanitary Permit Fee (Includes Groundwater ate Issue Issuing Age Si nature(No Sta ps <br /> roved ❑ )CQ CTU 5.r nage f ee) _ <br /> P Owner Given Initial [� <br /> Adverse Determination <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SRD-6398(R.05/94) 13MRIRUTION: Original to County,One ropy To: "rely&Ruildings Division,Owner,Plumber <br />