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c��, <br /> Safety and Buildings Division <br /> � <br /> Bureau of Building Water Systems <br /> �■�.,�. SANITARY PERMIT APPLICATION 201 E.Washington Ave. <br /> . <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 / 6176than 8 112 x 1 1 inches in size. ��N �f <br /> • See reverse side for instructions for completing this application State Sanitary Permit Number <br /> ,31!no 6 7c?-- <br /> The information you provide may be used by other government agency programs ❑Check it revision to previous application <br /> IPrivacy Law,s. 15.04(1)(m)I State Plan I.D.Number <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INF MATION <br /> Property Ow er Name /+Prp/fe oc �4 nS 3 T 38 r N, R /8 E(or <br /> Property Owner's Mailing Address t Number Block Number <br /> City,State Zip Code Phone Number Sabdivisiefl-Plaa>eor CSM Number <br /> II. TYPE OF BUILDING: (check one) ❑ State Owned ❑ City Nearest Road <br /> E] Public 1 or 2 FamilyDwelling- No. of bedrooms � ° Town of - �0',"i/kie P r^ xA—C r'171,4 <br /> 111. BUILDING USE: (If buildingtype is public,check allthatapply) Parcel Tax Number(s) <br /> 1 ❑ Apartment/Condo I y� 7�� y !S7/6 <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. Replacement 3_ ❑ Replacement of 4. ❑ Reconnection of 5. ❑ 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 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-Fi II <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) Elevation <br /> ID in �a �'� / 6 -9 ,7 Feet 9f Feet <br /> TANK Ca acit <br /> VII INFORMATION in Ballo s Total #of Manufacturer's Name Prefab. Con- Steel Fiber- Plastic Exper <br /> New Existin Gallons Tanks concrete strutted Blass App. <br /> Tanks Tanks <br /> Septic Tank or Holding Tank 1 ,700 C /� C�� ❑ ❑ 1 ❑ ❑ ❑ <br /> I ift Pump Tank/Siphon Chamber ❑ ❑ ❑ 1 ❑ ❑ ❑ <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.: �Bufs;inessPhone Number: <br /> GIjAcje5� y -7��'� <br /> Plumber's Address(Street,City,State,Zip Code): <br /> IX. COUNTY/ DEPARTMENT USE ONLY <br /> E]Disapproved Sanitary PermitFee (Indudes6roundwater ate issue ssuingA en igna re( oS mps) <br /> A roved (, Surcharge Fee) (/J <br /> pp ❑Owner Given Initial 5o <br /> Adverse Determination <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> Sart-6398(R.W94) DISTRIBUTION'. Original to Caunl y.One blPy To: 5afety&&uildings Oivuion,Owner,Plumber <br />