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Safety and Builivision <br /> SANITARY PERMIT APPLICATION Bureau 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 County <br /> \ <br /> than 8 1/2 x 11 inches in size. 6f )"Yi <br /> • See reverse side for instructions for completing this application State Sanitary Permit Number <br /> �2 �6 9 erg <br /> The information you provide may be used by other government agency programs ❑ eck 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 /> Perty Owner Name Propert Lobation <br /> u V K N E 1/4 to 1/4,S 3 � T <br /> Pr <br /> ,N, R� '& ora' <br /> PropertyOwne 'sMailing ddreySs Lot Number Block Number <br /> � _Il <br /> 11c11i � S <br /> Cit State Zip Code Phone Numb r Subdivision Name or CSM Number <br /> � (V.� W ' 87 2- (7/ 3`9-230) <br /> IL TYPE OF BUILDING: (check one) ❑ State OwnedIty Nearest Road <br /> ❑ Village ]� <br /> Public 1 or 2 FamilyDwelling- No.of bedrooms Z st Town of 2�Y10� tf uG f� t <br /> III. BUILDING USE: (If building type is public,check all that apply) Parcel Tax Numbers) <br /> 1 ❑ Apartment/Condo earf 600 <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- X 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 M 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 S. Pert. Rate 6. System Elev. 7. Final Grade <br /> ' / Required(sq.ft.) Proposed(sq.ft.) (Gals/day/sq.ft.) (Mi ch) Elevation <br /> `'t Q , -7 7—, 7 Feet S S'Feet <br /> VII. TANK Capacuty <br /> INFORMATION in allons Total #of Prefab. Site Fiber- Exper_ <br /> g Gallons Tanks Manufacturer's Name Concrete Con- steel g ass Plastic App <br /> New Existing strutted <br /> Tanks Tanks <br /> Septic Tank r Holding Tank OC3 l Cit El ❑ 1-1 ❑ <br /> Lift Pump Tank/Siphon Chamber ❑ ❑ ❑ ❑ ❑ ❑ <br /> VIII. RESPONSIBILITY STATEMENT <br /> I,the undersigned,assume responsi lity for installation of the onsite sewage system shown on the attached plans- <br /> Plum ber' <br /> lans.Plumber' Name:(Pri t) Plumber'sSignatu e: oStamps) MP/MPRSW No.: Business Phone Number: <br /> �Sy I/ S-7 If 7lSG� p� <br /> P umber's Address(Street,Gty,State,Z p Code)., <br /> �Y. t <br /> IX. COUNTY/ DEPARTMENT USE ONLY <br /> �(� ❑Disapproved Sanitary Permit F e (includes Groundwater ate sue Issuin A Signa)ure(No 5 m ) <br /> 4A roved �� Surcharge fee) <br /> t( pp ❑Owner Given Initial ) a`cc,� T �/� <br /> Adverse Determination / <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(R 05194) DISTRIBUTION. Original to county,one copy To: Safety 8 Buildings Divmsion,Owner,Plumber <br />