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Oil 0Vyy4_1 1 <br /> _ Safety and Buildings Division <br /> SANITARY PERMIT Bureau of Budding Wa <br /> APPLICATION ter 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 12 x 11 inches in size. State Sanitary Permit Number <br /> • See reverse side for instructions for completing this application -301 of <br /> The information you provide maybe used by other government agency programs ❑ <br /> Check it revise n to p vious application <br /> (Privacy Law,s. 15.04(1)(m)1. State Plan I.D.Number <br /> 1. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION <br /> Property Location �j N, R / E(or <br /> 4PropertyOwner's <br /> me j / N64/4 gi1/4,$ 2l T 3p <br /> hLot Number Block Number <br /> ailing Address// f- Zige lhone NumberSubdivision Name or CSM Number <br /> 6 4 4* rNearest RoadUIL G: (check one) ❑ State Owned ❑ city �Q <br /> :3 Village / ,� <br /> oo <br /> Public 1 or 2 FamilyDwellin - No.of bedrooms Town OF 7i '` <br /> III. BUILDING USE: (If building type is public,check all that apply) <br /> Parcel Tax Number(s) <br /> 1 <br /> F1 Apartment/Condo O y,2 a Sa I o / S o C) <br /> 2 El Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility <br /> 3 ❑ Campground 7 ❑ Merchandise: Sales/Repairs 11 E] Restaurantion/Coining <br /> 12 Service Station/ Wash <br /> 4 ❑ Church/School 8 ❑ Mobile Home Park 13 ❑ Other: specify <br /> 5 ❑ Hotel/Motel 9 ❑ office/Factory <br /> IV. TYPE OF PERMIT: (Check only one box on line A. Check box on line B,if applicable) Repair of an <br /> New 2- Replacement 3. ED Replacementof 4. [:] Reconnection of 5. E] P <br /> A) 1. F1 System System Tank Onl-yExisting System - -------Existing System <br /> ----------------------- -------------------- -------------- <br /> B) ❑ A Sanitary Permit was previously issued. Permit Number <br /> Date Issued <br /> V. TYPE OF SYSTEM: (Check only one) <br /> Experimental <br /> Other <br /> Non-Pressurized Distribution Pressurized Distribution p <br /> 11 Weepage Bed 21 ❑Mound 30❑Specify Type 41 ❑Holding Tank <br /> 22❑In-Ground Pressure 42❑Pit Privy <br /> 12 E]Seepage Trench 43❑Vault Privy <br /> 13❑Seepage Pit <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. Elevtnl ataon rade <br /> ys—o Required(sq. ft.) Proposed(sq.ft.) (Gals/day/sq.ft.) (Min./inch) y Feet 9,3 Feet <br /> VII. TANK Capacity Site Fiber_ Exper <br /> in gallons Total #of Manufacturer's Name Concrete con- steel glass Plastic APP <br /> INFORMATION New Existin Gallons Tanksstrutted <br /> Tanks Tanks ❑ ❑ n <br /> Septic Tank or Holding Tank ©fl A ��� ❑ ❑ <br /> It,ft Pump Tank/Siphon Chamber 6649 <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 Signature:( oStamps MP/MPRSWNo.: Business Phone Number: <br /> Plumber's Name:(Print) <br /> Plumer'sAddress(Street,city,state,Zip�Code): <br /> IX. COUNTY/ DEPARTMENT USE ONLY <br /> L <br /> approved Sanitary Permit Fee (Indudes9 roundater ate Issue Isswn ntSignature NoStamps) <br /> SurhareFee) <br /> Approved ner Given Initial �U 'S�verse Determination <br /> CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SNt1-6398(R.05/94) <br /> DISTRIBUTION: original to County,one urliy To: Safety&Ruildinya Division,owner,Plumber <br />