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a p � Safety andBuildin Division <br /> �. �'■;�' 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 Count �. f/ii 8 1/2 (p <br /> x 11 inches in size. <br /> • See reverse side for instructions for completing this application State Sanitary Permit Numbhr <br /> The information you provide may be used b other government agency programs ��616 <br /> y p y y 9 9 y p 9 ❑Check if erosion to previous apVlicalion <br /> (Privacy Laws- 15.04(1)(m)]_ <br /> State Plan I.D.Number <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION S '- 7-C)5-6 <br /> ProfownejrN ame Propert Location <br /> 1, <br /> 4' 1/4,S T ,N, R IS' E(orW <br /> P 37 <br /> Prow M Ig Ad ress Lotumber ! Block Number <br /> D <br /> Ci a <br /> Zip Code Phone Number Subdivision Name or CSM Number <br /> ©� ( /,�) <br /> II. TYPE OF BUILDING: (check one) ❑ State Owned o City Ne rest Road <br /> Public 1 or 2 Famil Dwellin - No.of bedrooms �_ V ToVilwn OF ` <br /> III. BUILDING USE: (If building type is public,check all that apply) Parcel Tax Number(s) <br /> 1 ❑ <br /> 6,-341- <br /> Apartment/Condo /<-'I/— Ina 3(:z <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. IN Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an <br /> -----System --------System Tank Only--- Existing System ---------Existing System <br /> ------------- --------- <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 4114 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 <br /> rRe <br /> bsorp.Area 3. Absorp.Area 4. Loading Rate 5. P S stem Elev. 7. Final Grade <br /> uired(sq.ft.) Proposed(s (Min./inch) <br /> 6 Feet Feet <br /> Ca aclt <br /> VII. INFORMATION in gallons Total #of Manufacturer's Name Prefab Site Con- steel Fiber- Plastic Exper <br /> New JExistin Gallons Tanks concrete structed glass App. <br /> Tanks Tanks <br /> Septic Tank or Holding Tank XZb ® ❑ ❑ ❑ ❑ ❑ <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) u ber's Sign re:(No Stamps) MP/MPRSW No.: Business Phone Number: <br /> V 2- <br /> P umber' ddress Stree City,State,zip code): <br /> 2 <br /> IX. COUNTY/ DEPARTMENT USE ONLY <br /> ❑Disapproved Sanitary Permit Fe (lndudenGroundwater ate s ue Issuing Agent gna ore amps) <br /> roved surcharge Fee) �� <br /> ( App Owner Given Initial �o � 7 <br /> Adverse Determination <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(R.05/94) DISTRIBUTION: Original to county.One copy To: Safety 8 Buildings Divmlon,owner,Plumber <br />