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Jill (^ <br /> on <br /> M11LHR SANITARY PERMIT APPLICATION BufeauofBty and BuildingDivisstem. <br /> Bureau of Buildtn y <br /> In accord with ILHR 83 05,Wis.Adm.Code 207 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 than 8 112x 11 inches in size. <br /> • See reverse side for instructions for completing this application state Sanitary Permit Number <br /> The information you provide may be used by other government agency programs <br /> ❑Check if revision to pre ious application <br /> (Privacy Law,s. 15.04(1)(m)I- <br /> State Plan I.D.Numbar <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION <br /> Y)q— <br /> Property.pwner Name S Pr perty Location <br /> /4 NLJ 1/4,S T q, ,N, R S E(or(WI <br /> Property OwnerX Mailing Address ,��l/ // Lot Number Week.pQmMr <br /> ttame '� Vf &-7� CR'Ef <br /> City,State ' I Zip Code (hone u ber ! Subdiy cion N�me or CSM umber ber <br /> P. <br /> II. TYPE OF BUILDING: (check one) ❑ State Owned 7 o City r0 Nearest Road <br /> ❑ Public 1 or 2 Famil Dwellin - No. of bedrooms _3 ° Towan of 50In/JSS 84LE jfl <br /> 111. BUILDING USE: (If building type is public,check all that apply) Parcel Tax <br /> Number(s) <br /> 1 F1 Apartment/Condo 03Z 4Z_3 <br /> 2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 0.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.X 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 /> 11Seepage Bed 21 E]Mound 30 E]Specify Type 41 E] Holding Tank <br /> 12M 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 /> �O Required(sq- ft.) Pro osed(sq. ft.) (Gals/day/sq. ft.) (Min./inch) / Elevation <br /> 3 D -- 3_ b Feet b , Feet <br /> VII. TANK Capacity <br /> INFORMATION in gallons Total #of Manufacturer's Name Prefab. Site Fiber- Plastic Exper <br /> New Existin Gallons Tanks Concrete Con- Steel glass App <br /> strutted <br /> Tanks Tanks <br /> Septic Tank or Holding Tank ' 0 (� L 91 ❑ 01 01 11 ❑ <br /> Lift Pump Tank/Siphon Chamber DQ (000 <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: S mps) MP/MPRSW No.: Business Phone Number: <br /> P umber's Address(Street,City,State,Zip Code). <br /> W —ag GDS 1 CJS w r <br /> IX. COUNTY/ DEPARTMENT USE ONLY <br /> ❑Disapproved Sanitary Permit Fee IlndudesGrouRdwater ateIssuedIssuing_of Age t Sign ure No t psi <br /> roved Surcharge lee) <br /> PP ❑Owner Given Initial �y,-� �/� <br /> Adverse Determination T <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SRO-6398(R.05/9Q) DISTRIBUTION: Original to Cmua y,One copy 70: Safety 8 Buildings Divulon,owner,Plumbtr <br />