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Qr. <br /> Safety and Buildings visidn <br /> Ei i 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 County q �,--7g <br /> than 8 1/2x 11 inches in size. pu l <br /> • See reverse side for instructions for completing this application State Sanitary Per it Number <br /> ail 7317 <br /> The information you provide maybe used by other government agency programs ❑Check it revision to previous application <br /> I Privacy Law,s. 15.04(1)(m)I- State Plan I.D.Number / <br /> 1. ARRUCATION INFORMATION - PLEASE PRINT ALL INFORMATION / V <br /> r net Name Propert Location <br /> KU N 1/4 1/4,S IS T 40 N, R 1b E(or)© <br /> Property0 ner's Mailing Address Lot Numberr <br /> P. <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> I , o ) <br /> II. TYPE OF BUILDING: (check one) ❑ State Owned [] City Nearest Road <br /> Public 1 or 2 Famil Dwellin - No. of bedrooms �_ D Town of �E1J5FN Rh- <br /> III. BUILDING USE: (If building type is public,check all that apply) Parcel Tax Number(s) <br /> 1 ❑ Apartment/Condo d-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 <br /> IV. TYPE OF PERMIT: (Check only one box on line A. Check box on line B, if applicable) <br /> A) 1. ❑ New 2. ;4 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 /> 11 X 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.) (MinAnch) Elevation <br /> 3 $ Feet 0. 3 Feet <br /> Capacity <br /> VII. FORMATION in gallons Total #of Manufacturer's Name Prefab Site Con- Steel Fiber- plastic Exper <br /> New ExistingGallons Tanks Concrete glass App <br /> Tanks Tanks structed <br /> Septic Tank or Holding Tank (0001— I DOD I S AW ❑ I ❑ 1 ❑ ❑ ❑ <br /> L lft Pump Tank/Siphon Chamber, I I ❑ El 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) Plumbe�r's//signa�ture:(No5 mps) MP/MPRSW No.: Business Phone Number: <br /> I04 RD oP lnlS uM�c,A `{710 <br /> P b tuber's Add ress(Street,City,State, ip Code): <br /> 27 w 35 <br /> IX. COUNTY/ DEPARTMENT USE ONLY <br /> ❑Disapproved Sanitary Permit Fee (Iodudoi Groundwater at ssue Issuing Agen Igna ure(N S mps) <br /> Approved ❑Owner Given Initial <br /> Adverse Determination <br /> X. CONDITIONS OF APPROVAL/REASONS FOR ISAPPROVAL: <br /> SBD-6398(R.0"4) DISTRIBUTION: Original to count,Oneoo,To: Safety is Buildings 0m,mn,owner,Plumber <br />