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Safety and Buildings Division <br /> itC��R 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 8 112 x 11 inches in size. UmOr <br /> • See reverse side for instructions for completing this application State Sanitar PermitNumber <br /> The information you provide may be used b other government agency programs C( <br /> Y P Y Y 9 9 Y P 9 ❑Check it revision o previous application <br /> IPrivacy Law,s. 15.04(1)(m)I. <br /> State Plan I.D.Numb r <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION <br /> Propert Owner ame Property Location <br /> NP/4 5F 1/4,S 7Z T N, R 15 E (or W <br /> Property Ow er's Mailing Address Lot Number Block Number <br /> T-iq a . JRD. 13 1 <br /> Cit ,,State �' Zip Code Ph neNumb r- Subdivision ameAr��Number <br /> ( ) L S <br /> II. TYPE OF BUILDING: (check one) ❑ State Owned ❑ City Nearest Road <br /> Public 1 or 2 FamilyDwelling- No.of bedrooms 3 PT o Town of CA FOCL [[l <br /> III. BUILDING USE: (if building-type ispubhc,checkallthatapply) Parcel TaxNumber(s) <br /> 1 E] Apartment/Condo 61V—,-299-,2-02 ` 3(no <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. M 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 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 5. Perc. Rate 6. System Eley. 7. Final Grade <br /> QL"7� <br /> Required(sq. ft.) Proposed(sq. ft.) (Gals/day/sq. ft.) (Min./inch) o Elevation <br /> 1� 0Q �(� S �'-- q o•3S Feet .Ss Feet <br /> TANK" Ca al VII INFORMATION in gallons Total #of Manufacturer's Name Prefab Con- Steel Fiber-Site Exper <br /> New Existin Gallons Tanks Concrete strutted glass Plastic App <br /> Tanks Tanks <br /> Septic Tank or Holding Tank too ❑ ❑ ❑ ❑ ❑ <br /> Lift Pump Tank/Siphon Chamber ❑ ❑ ❑ ❑ ❑ ❑ <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:(Pant) Plumber's Signature: o mps) IMP/MPRSWNo : Business Phone Number: <br /> ,ctlaR o Ns waN( 34zb I5- g(6- tS� <br /> PI mber's Address(Street,City,Slate,Zip Code): <br /> 2-77(go Ijw s LdI . .S-FSy� <br /> IX. COUNTY/ DEPARTMENT USE ONLY <br /> ❑Disapproved Sanitary Perm Fee (Indcdes Groundwater Date Issue Issuing Ag Sigpa N Stamps) <br /> 1f Approved ❑Owner GivenInitial ��! urcnargelee) / /7 <br /> 1C \\ Adverse Determination ,56 !� f` 7 <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SND-6398(R.05/94) DISTRIBUTION original to Cme,ty,One cupy To: Safety 8 9uildinge Nve.ion,Owner,Plumber <br />