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Safety and Buildings Division <br /> 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 /> • Attach complete plans(to the county copy only)for the system,on paper not less County <br /> than 8 1/2 x 11 inches in size. �41f r/1 1019T <br /> -73• See reverse side for instructions for completing this application State Sanitary Pe�riit Number <br /> information you provide may be used by other government agency programs ❑Check it revision to prev/i/us application <br /> [Privacy Law,s. 15-04(1)(m)]. State Plan I.D.Number <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION I �5�2'�'b`?4 <br /> Prtp,vfty Owner Name Property Location <br /> Z@ccJS 1 ,�G1/aS€ 1/4,S t(p T 3B;N, RI *JM),? <br /> Pro+ep��erty Owner's Mailing Add res, \ 1- Lot Number / Block Number <br /> JI. �t I <br /> CitySt to Zip Code Phone Number Subdivision Name or CSM Numb r <br /> WQI� LK wk( s—t Z (&Z-)4210 (• l �'� <br /> II. TYPE OF BUILDING: (check one) ❑ State Owned Lity Nearest Road <br /> I '2 <br /> Public 1 or 2 FamilyDwelling ❑ Village- No.of bedrooms Town of a n t-ecs I d JS <br /> III. BUILDING USE: (If building type is public,check all that apply) Parcel TaxNumber(s) <br /> 1 ❑ Apartment/Condo <br /> Pr}, o� oto a I1�7 -OB 700 <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. rN New 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an <br /> ---- System System ------------- Tank Only---------------Existing System-- ___ Existing System <br /> -------- <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 KHolding 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. Perc. Rate 6. System Elev. 7. Final Grade <br /> Required (sq.ft.) Proposed(sq.ft.) (Gals/day/sq.ft.) (Min./inch) Elevation <br /> J � Feet Feet <br /> Capact <br /> VII. TANK in allons Total #of Prefab. Site Fiber- Exper. <br /> INFORMATION g Gallons Tanks Manufacturer's Name Concrete Con' Steel glass Plastic App <br /> New Existingstructed <br /> Tanks Tanks <br /> H <br /> Septic Tank o olding Ta %h/ � ( ❑ El I Q I El El <br /> Lift Pump Tank/Siphon Chamber I I El 1 ❑ El I Ej I El EJ <br /> VIII. RESPONSIBILITY STATEMENT <br /> Ill I,the undersigned,assume responsi i]ity for installation of the onsite sewage system shown on the attached plans. <br /> P m er s e:(P nt P umber'sSign ur .(No Stamps) MP/MPRSW No.: Business Phone Number: <br /> Plumber's Address(Street,Cit , tate,L ): ` �_.rcc?f <br /> IJS'r4X.{� J ` <br /> IX. C UNTY/DEPARTMENT USE ONLY <br /> E]Disapproved Sanitary Permit FEEe..((includes Groundwater Date Ap �1MJiu <br /> ue Issuing Agent Si atur No s) <br /> rcbarge ree) <br /> proved ❑Owner Given Initial <br /> Adverse Determination <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(R.05/14) DISTRIBUTION: Original to County,One copy To: Safety&Building,Division,Owner,Plumber <br />