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1 'Safety and Buildings Division <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 Count 13� <br /> than 8 1/2 x 11 inches in size. l,44 (� <br /> • See reverse side for instructions for completing this application State Sanitary Permit Number 7u <br /> The information you provide may be used by other government agency programs ❑Check it revision to previous application <br /> [Privacy Law,s. 15.04(1)(m)]. State Plan I.D.Number/� <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION —rI 1013 <br /> Pro erty Owner Name Property Location <br /> a E 1/4,S/0 T_,3g ,N, R E(orK@ <br /> Property Owner's Mailing Address Lot Number Block Number <br /> l 70 <br /> City,State I Zip Code Phone Number Subdivision Name or CSM Number <br /> 11. TYPE OF BUILDING: (check one) ❑ State Owned ❑ it� Nearest Road / <br /> Public 1 or 2 FamilyDwelling-No.of bedrooms vown OF0 7!e C/ / e <br /> III. BUILDING USE: (If building type is public,check all that apply) Parcel TaxNumber(s) <br /> 1 ❑ Apartment/Condo G O 6 —4;7C!O3 20,0 <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 f/ <br /> IV. TYPE OF PERMIT: (Check only one box on line A. Check box on line B, if applicable) <br /> A) 1. F5eNew 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5- ❑ Repair of an <br /> -__ ystem ____ 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 ❑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. Rate 5. Pert. Rate 6. System Elev. 7. Final Grade <br /> 9 <br /> Required (sq. ft.) Proposed(sq. ft.) als/day q.ft.) (Min./inch) _ Elevation <br /> Feet <br /> Capact <br /> VII. INFORMATION in gallons Total #of Manufacturer's Name Prefab. Con- Steel Site Fiber- Plastic Exper <br /> New Exist Gallons Tanks Concrete glass App. <br /> TankAs Tanks strutted <br /> Septic Tank or Holding Tank �pQ om y-e(� �-- ❑ ❑ ❑ ❑ ❑ <br /> Lift Pump Tank/Siphon Chamber I 1 ❑ ❑ ❑ ❑ ❑ ❑ <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:(N Stamps) MP/MPRSW No.: Business Phone Number: <br /> Plumber's Address(Street,City,State,Zip Code): <br /> lJ S/ <br /> IX. COUNTY/ DEPARTMENT USE ONLY <br /> ❑Disapproved Sanitary Permit Fee f n`�udes6mundwater ate Issue Issu ng ent Signature(No Stamps) <br /> Approved ❑Owner Given Initial _ nar9e lee) ' <br /> Adverse Determination -I���`00 "T-al-�g <br /> NDITIONS OF APPROVAL/ REASONS FOR DISAPPROVAL: <br /> San-6398(It,05/94) DISTRIBUTION: Original to Cmrra y,One a/Py To: Satety&Rulldin9t Division,Owner,pi.miZr <br />