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G� <br /> Safety and Buildings Divisio <br /> �. 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 8 vi x 11 inches in size. E? <br /> • See reverse side for instructions for completing this application State Sanitary Permit Numb r <br /> SX 08 <br /> The information you provide may be used by other government agency programs ❑Check It revision to previous application <br /> IPrivacy Law,s. 15.04(1)(m)l. State Plan I.D.Number <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION ci <br /> Property Owner Name Property Location Gov, ,/ I1` <br /> �GLty\ s X1/4 NU/4,S j 9 T y() ,N, R/`/ V(or)W v <br /> Propert Owner's Mailing Address Lot Number Block Number <br /> a 3 6 rJ <br /> City,State Zip Code Phone Number 5abdwn er#awa or CSM Number <br /> t�J bs-�ce ( ( )A401e.50000 Vol15 <br /> II. TYPE OF B ILD110 (check one) ❑ State Owned ❑ city Nearest Road <br /> E] Village <br /> El Public 1 or 2 Family Dwelling- No.of bedrooms 2 Town of7)A4f--rAl <br /> III. BUILDING USE: (If building type is public,check all that apply) - Parcel Tax Number(s) g <br /> 1 E] Apartment/Condo O�9t—"/// 05. 76 <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. KReplacement 3. ❑ Replacement of 4, ❑ Reconnection of 5_ ❑ Repair of an <br /> System System _______ _ Tank Only___ _______ Existing System___ ____ExistingSystem <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 OdSeepage 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 S. Perc. Rate 6. System Elev. 7. Final Grade <br /> Required(sq.ft.) Pro os3ed,�sq.ft.) (Gals/day/sq. ft.) (Min./inch) Ele ation <br /> �� e Feet Feet <br /> Ca aat <br /> VII. FORMATION in gallons Gdlltons Tanks Manufacturer's Name Concrete ette Prefab Co steel g ass Plastic App, <br /> New Existin strutted <br /> Tanks Tanks <br /> Septic Tank or Holding Tank �{Sl7 15� I Q� ❑ ❑ ❑ El ❑ <br /> Lift Pump Tank/Siphon Chamber ❑ ❑ ❑ ❑ ❑ I ❑ <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) P bi Signature:( s MP/MPRSW loo usi ss Phone Number: <br /> Cv A (ri a qj5 63 - 3�3 <br /> ' ddre (Street,Cit ,State,Zip Due),/ <br /> 6bk 7 <br /> IX. COUNTY/ DEPARTMENT USE ONLY <br /> ❑Disapproved Sanitary Permit Fee (includesGroundwaler Date ssue Issu ling Agent Signature( o mps) <br /> ` <br /> proved ❑Owner Given Initial Surchargeree) <br /> Adverse Determination <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SND-6398(11.05/94) DISTRIBUTION Original to court,One oiPy To: Safety B Buildings Olmuon.Owner,Plumtrer <br />