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Safety and Buildings Division <br /> SANITARY PERMIT APPLICATION Bureau of Building Water Systems <br /> �:■ <br /> f��L.,77t1 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 <br /> than 8 112 x 11 inches in size. >��(� ,7, �6 <br /> • See reverse side for instructions for completing this application State Sanitary Numpw 1 <br /> The information you provide may be used by other government agency programs ❑Check if revision to previous application <br /> [Privacy Law,s- 15-04(1)(m)]. State Plan I.D.Number <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION <br /> Property Owner Name Property Location /� <br /> �/& N C/S mss,u $W1/4 �� 1/4,S 3-15-- T � ,N, R& E(or)Q <br /> Property Owner's Mailing Address Lot Number Block Number <br /> /s,_-5--6 go -5:7— 0 c v <br /> City,State Zip Code Phone Number Subdivision Nam gCSM Nu ber / <br /> II. TYPE OF BUILDING: (check one) ❑ State Owned ❑ city Nearest Road <br /> Public or 2 Family Dwelling- No.of bedrooms ° Town OF J9J ee.u� u <br /> d�,q.l.i S <br /> III. BUILDING USE: (If building type is public,check all that apply) Parcel TaxNumber(s) <br /> B _2 1 ❑ Apartment/Condo 16 - <br /> 2 <br /> ❑ 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 /> S ❑ 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 __ ExistingSystem <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-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.) (Min./inch) Elevation <br /> Feet <br /> TANK Ca act <br /> VII. INFORMATION in gallons Total #of Manufacturer's Name Prefab. ion_ Steel Fiber- Plastic Exper <br /> New Existin Gallons Tanks concrete strutted Blass App. <br /> Tanks Tanks <br /> Septic Tank or Holding Tank 7�� 7S C� .f7,7 - ❑ ❑ ❑ ❑ ❑ <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 lNo Stamps) MP/MPRSW No.: Business Phone Number: <br /> l)AdlF_ Osl111.> Xi'-e_ -- 1 tel' <br /> Plumber's Address(Street,City,State,Zip Code): <br /> B X .�� SJ�i^ <_.-�.) Gam✓-•`-'— =5'�! � �-- <br /> IX. COUNTY/ DEPARTMENT USE ONLY <br /> ❑Disapproved r <br /> itary Permit Fee (includes Groundwater ate IssuedIssuing Agen gna re( mps) <br /> proved ❑Owner Given Initial <br /> charge fee) 1;ZA � <br /> Adverse Determination <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(8.DS/94) DISTRIBUTION: Original to County,One copy To: Safely&Buildings Division,Owner,Plumber <br />