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QN <br /> On ��Safety andBuildng Division <br /> SANITARY PERMIT APPLICATION BureauofBuildingWater System201 E.Washington AveIn 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 <br /> than 8 1/2 x 11 inches in size. O <br /> • See reverse side for instructions for completing this application State Sanitary Permit Number <br /> 3 The information you provide may be used by other government agency programs 00685 <br /> l Privacy Law,s. 15.04(1)(m)I. ❑Check if revision to previous application <br /> State Plan I.D.Number V <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION 1. 5_77 ;Z16117 C <br /> Property Owner N mg q ,/ P arty Location ", <br /> �r / f3 �c/ N 1,1 �� 1/4,S.31 T �Q r N, R �� E(orv_vyvy <br /> Property Own/er's Mailing Address Lot Number Block Number <br /> City,Statele Zip Code Phone Number Sa�ivrisiew#ame or CSM Number <br /> r �� _T_54'f0 ( <br /> II. TYPE OF BUILDING: (check one) ❑ State Owned ❑ ity Nearest Road <br /> Public 1 or 2 FamilyDwelling- No. of bedrooms -�� LITo n of (J!4l"lj <br /> III. BUILDING USE: (If building type is public,check allthatapply) Parcel TaxNumber(s) <br /> 1 Q Apartment/Condo 0.;.?� e — <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 <br /> 5 ❑ Hotel/Motel gOffice/Factory <br /> 12 E] Service Station/Car Wash <br /> ❑ Office/Factory 13 Q Other: specify <br /> IV. TYPE OF PERMIT: (Check only one box on IineA. Check box online B, if applicable) <br /> A) 1. ,KNew 2_ ❑ Replacement 3. ❑ Replacement of 4_ ❑ Reconnection of 5stem . ❑ Repair of an <br /> ------System System Tank Only_________ ExlstingSy--- _ 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 Q Seepage Bed 21 ❑Mound 30❑Specify Type 41 5&Holding Tank <br /> 12❑Seepage Trench 22 Q 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 /> Feet <br /> VII. TANK Capacity <br /> INFORMATION in gallons Total #of Manufacturer's Name Prefab Site Fiber- Exper <br /> New Existin Gallons Tanks Concrete Con- Steel glass Plastic App <br /> Tanks Tanks strutted <br /> Septi. 4 or Holding Tank QpZ �Otrp __ f ❑ ❑ E I n <br /> I fft Pump Tank/Siphon Chamber ❑ El El El <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:(N 0Atamps) MP/MPRSWNo.: Business Phone Number: <br /> Plumber's Address(Street,City,State,Zip Code): <br /> IX. COUNTY/ DEPARTMENT USE ONLY <br /> E]Disapproved Sanitary Permit Fe (includes chargeoundwater �� 9 Issuing Agent S nature( S m <br /> roved zurcnargeree) <br /> Pp Owner Given Initial Q ��_ <br /> Adverse Determination <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBU-6398(8.05/94) DISTRIBUTION. original to cmuo,One copy To: Safety&Buildings Dim:ion,Owner,Plumber <br />