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(7))1 <br /> Safety and Buildings D Ision <br /> V7� L1f�7 SANITARY PERMIT APPLICATION 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 County © <br /> than 812 x 11 inches in size. <br /> • See reverse side for instructions for completing this application Sta esanicary Pr t N beL� <br /> The information you provide may be used by other government agency programs ❑check revlston to previous application <br /> (Privacy Law,s. 15.04(1)(m)). <br /> State Plan I.D.Numbe <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION <br /> Property Owner Nam Property Property Location <br /> 2p L7 Int I'l A"er i4 Is41/4,S T31 7 N, R t W <br /> Proper y Owner's Mailing Address Lot Number Block Number <br /> 4 LaA,t3 <br /> City,Stater Zip Code Phone Number Subdivision Name or CSM Nu bef t <br /> ujg to <br /> II. TYPE OFBUILDING: (check one) ❑ State Owned ❑ Ut Nearest Road <br /> ❑ Village <br /> ❑ Public 1 or 2 FamilyDwelling-No. of bedrooms Town OF V',p (� <br /> :II. BUILDING USE: (If building type is public,check allthat apply) Parcel TaxNumber(s) <br /> 1 ❑ Apartment/Condo D 1 D --�;_ d� —3 <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, ❑ New 2. g 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❑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 Ele 7. Final Grade <br /> , 1 Required (sq.ft.) Pro osed (sq.ft.) (Gals/day/sq.ft.) (Mid/ifh) Elevation <br /> Lil s- 6 3 , r Feet /J,3 Feet <br /> TANK Capacit <br /> VII INFORMATION in allons Total #of Prefab. Site Fiber- Plastic Exper. <br /> Gallons Tanks Manufacturer's Name concrete Con- steel glass App. <br /> New Existin strutted <br /> Tanks TanksI //�� <br /> Septic Tan or Holding TankXI <br /> o L�1 [I—j—d ❑ [I ❑ 1:1 <br /> Lift Pump Tank/Siphon Chamber ❑ ❑ ❑ ❑ ❑ ❑ <br /> VIII. RESPONSIBILITY STATEMENT <br /> I,the undersigned,assume responsillility for installation of the onsite sewage system shown on the attached plans. <br /> Plumber's Name:( rent PI mber'sSigna re) oStamps) Business Phone Number: <br /> U <br /> Plumber's ddress( reet,Cit ,Sta,e,Zlp 7e1: <br /> IX. COUNTY! DEPARTMENT USE ONLY <br /> E]Disapprove( Sanitary Permit Fe (includes Groundwater at ss a ssuingAgeotSign ture mps) <br /> AAproved JOY I Surcharge fee) <br /> p ❑Owner Given Initial U <br /> Adverse Determination <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SRD 6398(R.Ob194) DISrRIRUTION Original to County,One copy To: Safety 8 Ruild Ings Diwaion,Owner,Plumber <br />