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�xx o mCen400 <br /> Safety and Buildings Division <br /> v� nn SANITARY PERMIT APPLICATION Bureau of Building Water System <br /> 201 E.Washington Ave. <br /> In accord with ILHR 83 05,Wis.Adm.Code P.O Box 7969 <br /> Madison,WI 5370707-796 <br /> • Attach complete plans(to the county copy only)for the system,on paper not less County /� <br /> than 8 1/2 x 11 inches in size. ,�eii sJ� �6 7C;7'3 <br /> • See reverse side for instructions for completing this application State Sanitary Permit Number <br /> The information you provide may be used by other government agency programsQ��9 <br /> ❑Chec revision previous application <br /> lPrivacy Law,s. 15.04(1)(m)]. State Plan I.D.NtJ/nb r <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION <br /> Property Owner Name ® Property Location ,� , <br /> kifi4/`a/ CBO 1/4 1/4,S -7-yT 3 7 ,N, R 1jr E(or�> <br /> Property Owner's Mailing Address Lot Number Block Number <br /> B V Q+ <br /> City',State Zip Code Phone Number Subdivision Name or CSM Number LVtp I C( <br /> ,^,C.-✓ G./ S'y87:Z ( ) f_6L�/ <br /> II. TYPE OF BUILDING: (check one) ❑ State Owned C ty Nearest Road <br /> Public1 2 Family <br /> o <br /> or amDwelling- No. of bedrooms vil�age �.yy1� <br /> ❑ lliTown OF/ove—e -�0 't �� fJ 0/s/L� <br /> III. BUILDING USE: (If building type is public,check all that apply) Parcel TaxNumber(s) e� <br /> 1 ❑ Apartment/Condo 0 /,v <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. 15i) New 2_ E] Replacement 3_ ❑ Replacement of 4. F] Reconnection of 5. ❑ Repair of an <br /> -____ ystem __ System _ Tank Only _______ Existing System___ Existing System <br /> B) p 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 /> 114 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 /> �7 Required (sq. ft.) Proposed(sq.ft.) (Gals/day/sq.ft.) (Min./inch) p6/ Elevation <br /> 0 e) o 6 �O s- / Feet 98. Feet <br /> Ca acct <br /> VII. TANK in gallons Galloal #ofons Tanks Concrete Site steel Fiber- Exper. <br /> INFORMATION New Existin Manufacturer's Name Con_ glass Plastic App <br /> Tanks Tanks strutted <br /> Septic Tank or Holding Tank g�(1 �Ot� ,� �¢[.eJ` <br /> Lift Pump Tank/Siphon Chamber <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:( oStamp MP/MPRSW No.: Business Phone Number: <br /> . aiA (I S�io�i� IV I .73el 1 <br /> Plumber's Address(Street,City,State,Zil Code): <br /> IX. COUNTY/ DEPARTMENT USE ONLY <br /> ❑Disapproved Sanitary Permit Fee (tndudescroundwater ate Is ue t� Issuing en ignatur (No <br /> �pprc d ❑Owner Given Initial ��A Surcharge Fee) 9 <br /> "�� Adverse Determination <br /> X. CONDITIONS OF APPROVAL/REASONS FO DISAPPROVAL: <br /> SHO 6398(H.05/94) DISTRIBUTION: Original to Cn unty,One[upy To: S;dety 8 Rudd,.%Division,Owner,Rlumk,zr <br />