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Safe yI(B'uilchngsivision <br /> SANITARY PERMIT APPLICATION Bureau of 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 812 x 11 inches in size. (> /'Z `79YG <br /> • See reverse side for instructions for completing this application State Sanitary Permit Number <br /> a9 / 7(o2 _ <br /> The information you provide may be used by other government agency programs ❑Check if revision to previous application <br /> (Privacy Law,s. 15.04(1)(m)]. <br /> State Plan I.D.Number <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION 1__%� <br /> Property Owner Name r Property Location <br /> C v4 _5c� v4,S�� T y�y ,N, R E(or� <br /> Property Owner's Mailing Address Lot Number Block Number <br /> 1316 <br /> City,State p t / /J Lp Code Phone Number Subdivision Name or CSM Number <br /> /V -W Ayc�l/hon r� — q U/S�a _�yz <br /> 11. TYPE OFBUILDING: (check one) E] State Owned ❑ ity Nearest Rpad� <br /> ❑ village /'ter <br /> Public 1 or 2 FamilyDwelling- No. of bedrooms Town OF .S c o L a A <br /> III. BUILDING USE: (If building type is public,check all that apply) Parcel Tax Number(s) <br /> 1 ❑ Apartment/Condo <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. CKNew 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ Reconnection of S. ❑ 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 /> 1 1 ®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 Elev. 7. Final Grade <br /> Required(sq. ft.) Proposed(sq.ft.) (Gals/day/sq. ft.) (Min./inch) �T Elevation <br /> CQC C) — / ,3 Feet 9S 7Feet <br /> TANK Ca act <br /> VII. INFORMATION in gallons Total #of Manufacturer's Name Prefab. Site Con- steel Fiber- plastic Exper <br /> New Existin Gallons of <br /> concrete strutted glass App. <br /> Tanks Tanks ^� �r <br /> Septic Tank or Holding Tank ��O /.5 C Q ❑ ❑ I ❑ I ❑ ❑ <br /> Lift Pump Tank/Siphon Chamber I ❑ ❑ ❑ I ❑ 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) Plumber's Signature:(No Stamps) MP/MPRSW No.: Business Phone Number:nas <br /> / <br /> Plumber's Address(Street,City,State,Zip Code): <br /> .,de �,' S _5 i/` P .� !�✓ S .2- <br /> IX. <br /> 2IX. COUNTY/ DEPARTMENT USE ONLY <br /> ❑Disapproved Sanitary Permit Fee (In`lude Groundwater ate s727T4� <br /> g Agent Si nature(N t ps) <br /> proved � /-� °rcnarge reel <br /> pp ❑Owner Given Initial / 9 <br /> Adverse Determination / `3 <br /> X. CONDITIONS OF APPROVAL/ REASONS FOR DISAPPROVAL: <br /> SBD-6398(R.05N4) DISTRIBUTION. Original to County,One copy TO: Safety&Buildings Division,Owner,Plumber <br /> I <br />