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Safety and Buildings Division <br /> SANITARY PERMIT APPLICATION Bureau of Building Water System: <br /> In accord with[LHR 83.05,Wis.Adm.Code 201 E.Washington Ave.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 8 112 x 11 inches in size. R :;'— <br /> See reverse side for instructions for completing this application state sanitary PRrmiitt N mmbb� <br /> The information you provide may be used by other government agency programs o ❑Check 03C tb previoGs ar plication <br /> [Privacy Law,s. 15.04(1)(m)1. rte r l State Plan I.D. " 'er / C <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION <br /> Property Owner Name Property Location ,l <br /> �O C� ESE 1/4�C 1/4,S NT �� N, R j`t E(or)( <br /> Propertywner's Mailing ddress Lot Number e+e�k dyer <br /> O 4 4'- /}V. S . S t�cR ES <br /> (ity,State Zip CodePrhone Nu ber Subdivision Name or CSM Number <br /> MPDS M� $$ p(, (01Z. ) 2Z_5 -11 <br /> II. TYPE OF BUILDING: (check one) ❑ State Owned ! <br /> ty Nearest Road <br /> El Public 1 or 2 FamilyDwelling-No.of bedrooms ,3 o village <br /> Town OF Sco Vle Rj7. <br /> III. BUILDING USE: (If building type is public,check allthatapply) Parcel TaxNumber(s) c� <br /> 1 ❑ Apartment/Condo 4� �I T,1q /v0 <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- M Sew 2. E] Replacement 3. ❑ Replacement of 4. E] Reconnection of 5_ ❑ Repair of an <br /> ______System __System __ Tank Only_____________ Existing System SSSS _ExlstingSystem <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 DI 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 /> Sb Required(sq. ft.) Proposed(sq.ft.) (Gals/day/sq.ft.) (Min./inch) rp� Elevation <br /> 3,7 ">- 37 1.Z. �--� -I Q• I Feet 101,3$ Feet <br /> VII. TANK Capau <br /> INFORMATION in gallons Total #of Manufacturer's Name Prefab. Site Fiber- Exper. <br /> New Existin Gallons Tanks Concrete Con- Steel glass Plastic App <br /> Tanks Tanks strutted <br /> Septic Tank or Holding Tank ` ,� oo� ❑ 1:1 ❑' <br /> Lift Pump Tank/Siphon Chamber p I I El ❑ 0 <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 tamps) MP/MPRSW No.: Business Phone Number: <br /> IC SLI �$- _ �c <br /> P mber's Address(Str et,City,State,Zip Code): <br /> IX. COUNTY/DEPARTMENT T USE ONLY <br /> ❑Disapproved Sanitary Permit Fee 0'd desGmundwater ate M <br /> Issuing Agent natur o Sta <br /> pproved ❑Owner Given Initial ` hargeFee) �f/ C <br /> ���ccc���ccdlllll Adverse Determination WL/ <br /> X. CONDITIONS OF APPROVAL/REASO S FOR DISAPPROVAL: <br /> SBD-6398(8.05/94) DISTRIBUTION: Original to County.One copy To: Safety 8 Buildings Divtsion,Owner,Plumber <br />