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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 /> Madison,WI 53707-7969 <br /> • Attach complete plans(to the county copy only)for the system,on paper not less County <br /> than 81/2 x 11 inches in size. <br /> • See reverse side for instructions for completing this application State Sanitary Per t Nuirriber <br /> The information you provide may be used by other government agency programs CP 6 �g / <br /> [Privacy Law,s. 15.04(1)(m)]. ❑Check it revision to previous application <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION State Plan I .Number <br /> �1 <br /> Property Owner N me � <br /> Prop L cation I <br /> va 5 1/4,S 2$ T N, FR E(or <br /> Property Owner's Mailin ddress ' <br /> 31� W Lot Number/ rI r <br /> ty, tate Zip CD�J P ne N IN Subdivision Name o M Numb <br /> 4,101- <br /> II. TYPE F BUILDING. (check one) ( � ) /3 9 <br /> ❑ State Owned ❑ CitIN est Road <br /> Public EL-or 2 FamilyDwelling- No.of bedrooms 2— village <br /> Town OF <br /> III. BUILDINGUSE: (If building type is public,check all that apply) Parcel Tax Number(s) <br /> 1 ❑ Apartment/Condo Pr-14- 016 - 3-3.26 - 0c2 <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 120 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 q. Reconnection of <br /> System _ System Tank Only ❑ 5. ❑ Repair of an <br /> ____________________Y_______ -Existing System ExistingSystem <br /> --------------- -y---- <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 /> 1 1,M Seepage Bed 21 ❑Mound 30 El Specify Type <br /> 41 E]Holding Tank12❑Seepage Trench22❑In-Ground <br /> Pressure <br /> 13 42 El Pit Privy <br /> ❑Seepage Pit <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. 7. Final Grade <br /> Re ire (sq. ft.) ProP9seOsq. ft.) (Galway/sq.ft.) (Min./inch �1 <br /> fl0 �� /)� rl evation <br /> VII. TANK Capacity 1 -1 Feet 6.Q Feet <br /> INFORMATION In gallons Total #of Prefab. Fiber- 4plastic er <br /> Gallons Tanks Manufacturer's Name SiteNew Exi _I_ Concrete stCon- Steel glass ppanks TnksSeptic Tank or Holding Tank ❑ ❑ ❑ ❑Lrft Pump Tank Siphon Chamber ❑ lVIII. 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:( o S mps) MP/MPRSW No.: <br /> (�. Business Phone Number: <br /> cStAQo Pkrn/ 3 26 7iS 866- (57 <br /> PI tuber's Address(Street,City,State,Zip Code): T <br /> Z'l-1 GO 44 35 JEA-smiz 4.11. S�{893 <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑Disapproved Sanitary Perrn F e (includes Groundwater ate sue Issuing Agen�e(Neas <br /> Approved ❑Owner Given Initial �0 Surcharge fee) '7 <br /> Adverse Determination / CrC� ! ;2 j� <br /> X. CONDITIONS OF APPROVAL/REASONS F R DISAPPROVAL: <br /> SRD-6398(R.85/94) DISTRIBUTION. Original to county,One copy To: Safety 8 Buildings Division,Owner,Plumber <br />