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afety and Buildings Division <br /> �p•Y"; 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 /> It <br /> • Attach complete plans(to the county copy only)for the system,on paper not less Coun <br /> than 8 12 x 11 inches in size. Le <br /> • See reverse side for instructions for completing this application State <br /> `Sanitary <br /> (Permit Nu9ber <br /> The information you provide may be used by other government agency programs ❑Ch�eKiI' istiefi to�i F Zpi catiun <br /> [Privacy Law,s- 15.04(1)(m)I. State Plan I.D.Number <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION �---� <br /> Prope yOwne Name Property Location <br /> 7'�_1/4 4/4,S T 7 S,N, R o�-ilmiliisr)(W <br /> Property wner's Mailing Address Lot Number Block Number <br /> Cid 5fate„ ,l � Zip Cod P�hZone Number Subdivision Name or CSM Number 7# 4 <br /> II. TYPE OF BUILDING: (check one) ❑ State Owned ❑ City Nearest Road <br /> ❑ Village <br /> Public jj 1 or 2 Family Dwelling- No. of bedrooms Town of /f Zjt& D <br /> Ill. BUILDING USE: (If building type is public,check all that apply) Parcel TTaaaxx Number(s) <br /> 1 ❑ Apartment/Condo ” / <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_ ❑ Replacement 3. E] Replacementof 4_ ❑ Reconnection of 5_ E] Repair of an <br /> System <br /> _ System _ ______ __ Tank Only ____ _______ExistingSystem ........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 ❑Seepage Bed 21 ❑Mound 30❑Specify Type 41 ❑Holding Tank <br /> 12Seepage Trench 2❑In-Gr u d Pressure 42❑Pit Privy <br /> 13 Seepage Pit //q // 43❑Vault Privy <br /> 14❑System-In-Fill 117 r 14 (� Pitt 2 <br /> VI. ABSORPTION SYSTEM INFO MATION: <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/d / q.ft.) (Min./inch) Elevation <br /> 3®® <br /> — $, Feet Feet <br /> VII. TANK Capacity <br /> Total #of Prefab. Site Fiber_ Exper <br /> INFORMATION in gallons <br /> Gallons Tanks Manufacturer's Name Concrete con- steel glass Plastic App. <br /> New Existin strutted <br /> Tanks Tanks <br /> eptic Tan rHolding Tank ©v Gls El r_1 r r r <br /> Lift Pump Tank/Siphon Chamber El 0 ❑ ❑ ❑ <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) Plumbisgnature:(N St a s) MP/MPRSW No.: Business Phone Number: <br /> 'PlurglIiier-9 Ad ss(Street4W /,46 0 ate,Zip Code): !K� 01 <br /> 15 C <br /> I . COUNTY/ DEPARTMENT USE ONLY <br /> ❑Disapproved Sanitary Permit Fee n<lodes croundwater ate Issue Issuing e#1 Signat a(No a s) <br /> proved ❑Owner Given Initial nrcnarge Fee <br /> Adverse Determination <br /> X. CONDITIONS OF APPROVAL/REASONS FO DISAPPROVAL: <br /> SND-6398(R.05/94) DISTRIBUTION: Original to county.One ropy To: Safety B Ruildings Divi,ion,Owner,Plumber <br />