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Safety and Buildings Division <br /> �'■��■�+ SANITARY PERMIT APPLICATION Bureau of Building Water Systems <br /> In accord with ILHR 83.05,Wis-Adm.Code 201 E Washington Ave. <br /> P.O.Box 7969 <br /> • Attach complete plans(to the county copy only)for the system,on paper not less tPlan <br /> Madison,WI 53707-7969 <br /> than 8 112 x 11 inches in size. f �q zy <br /> • See reverse side for instructions for completing this application efmit Nuuumlber `� / <br /> The information you provide maybe used by other government agency programs / <br /> (Privacy Law,s. 7 5.04(1)(m)]. n to previous application <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INF ORMATION ber <br /> Property Owner Name <br /> P operty cation <br /> va va,5 T N, R 1q E(or) <br /> Prope yOwner'sMailingAddress <br /> b of Number r <br /> City,5 ate 11 Zip Code Phone Number Subdivision Name or CSM Number <br /> aon1E 1j)• .IL '449,0 ( 6 ) S- 0 <br /> II. YPE F UILDING: (check one) ❑ State Owned ❑ city <br /> El Public 1 or 2 Famil Dwellin - No.of bedrooms 3 ❑ village /�n-r� Nearest Road <br /> gf Town OF S�-Vil (� ELk- V- <br /> III. BUILDIN USE: (If building type is public,check all that apply) Parcel Tax Number(s) <br /> 1 ❑ Apartment/Condo ®a� <br /> 2 ❑ Assembly Hall 6 ❑ Medical Facility/NursingHome <br /> 3 E] Campground 7 10 ❑ Outdoor Recreational Facility <br /> ❑ Merchandise: Sales/Repairs 111 <br /> 4 ElChurch/School 8 ElMobile Home Park ❑ Restaurant Bar/Dining <br /> 5 E] Hotel/Motel 12 ❑ Service Station/Car Wash <br /> 9 ❑ Office/Factory 13 E] Other: specify <br /> IV. TYPE OF PERMIT: (Check only one box on line A. Check box online B, if applicable) <br /> A) 1 o New System 2.*W 3tem . ❑ Tank cement of 4- ❑ Reconnection of 5. ❑ Repair of an <br /> ---- __ Y____ - - Existtn S stem <br /> ------------------------ -------g-y------------ Existing <br /> B) ❑ A Sanitary Permit was previously issued. Permit Number <br /> Date Issued <br /> V. TYPE OF SYSTEM: (Check only one) <br /> Non-Pressurized Distribution Pressurized.Distribution <br /> Experimental Other <br /> 11 Seepage Bed 21 [1 Mound <br /> 12 Seepage Trench 22 E]In-GroundPressure 30 El Specify Type 41 ❑Holding Tank <br /> 13❑Seepage Pit 42❑Pit Privy <br /> 14❑System-In-Fill 43❑Vault Privy <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.1 7. Final Grade <br /> D Requir d(sq. ft.) Proposed(sq.ft.) (Gals/day/sq.ft.) (Min./inch <br /> �t ) Elevation <br /> VII. TANK Capacity <br /> 1 �� (a. Z Feet q8,-7 Feet <br /> INFORMATION in gallons Total #of Prefab Site <br /> New Existin Gallons Tanks Manufacturer s Name Concrete Con- Fiber- Plastic Exper <br /> Tanks Tanks structed Steel glass App <br /> Septic Tank or Holding Tank y� ❑ ❑ ❑ ❑ ❑ <br /> Lift Pump Tank/Siphon Chamber P „ W ❑ ❑ ❑ ❑ ❑ <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'sSignatur oStamps) MP/MPRSW No.: Business Phone No ber: <br /> IcNgRp D IUn�S 7� /S <br /> P mber's Address(Street,city,Stat Zip Code): <br /> IlA <br /> IX. COUNTY/DEPARTM N USE ONLY �f3Sl•E� I g <br /> ❑Disapproved Sant ry Permit Fee (include, roundwater ate ssue Issuing Agent ignatu (No to <br /> '�pproved ❑OwnerGiveninitial C-0- surcnargeFee) ps) <br /> Adverse Determination So (9C <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SOD-6398(R.06/94) DISTRIBUTION: Original to Caunt y,One ropy To: Safety 8 Ruil.lings Division,Owner,Plumber <br />