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0-n (-'T <br /> on <br /> SANITARY PERMIT APPLICATION Safety of BuildingDivisstems <br /> Bureau of Buildin y <br /> 201 E.Washington Ave. <br /> In accord with ILHR 83 05,Wis.Adm.Code P -Box 7969 <br /> Madison,WI 53707-7969 <br /> • Attach complete plans(to the county copy only)for the system,on paper not less County �l <br /> than 8 112 x 11 inches in size. (o5 1�yU <br /> See reverse side for instructions for completing this application 5 ate Sanitary Permit Number <br /> The information you provide may be used by other government agency programs ❑Check 1evtsion to previous application <br /> [Privacy Law,s. 15.04(1)(m)]. <br /> State Plan LDNumber <br /> I. APPLICATION INFORMATION- PLEASE PRINT ALL INFORMATION <br /> Prope Owner Name Property Location <br /> QZ 114 1/4,S T N, R (o E(o W <br /> Prop rty Owner's Mailing Ad ress Lot Number Block Number <br /> 27 LIN co L-N ST1(3 <br /> - <br /> City,State Zip Code Phone Number Subdivisio Name or CSM Number <br /> l X4893 c�15> <br /> II. TYPEF BUILDING: (check one) ❑ State Owned -r ❑ it� Nearest Road <br /> Public 1 or 2 Family Dwelling-No.of bedrooms li ❑ To age ' y}� _ <br /> Town OF LTI' <br /> III. BUILDING USE: (If building type is public,check all that apply) Parcel TaxN`,ummber(s) <br /> 1 E] Apartment/Condo Mo JZZE © <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.gNew 2_ ❑ Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an <br /> System ----- System - ---- - -- Tank-Only- --- -- Existinq 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 /> 11epa�e$ed 21 E]Mound 30 E]Specify Type 41 ❑ Holding Tank <br /> 12 Seepage Trench 22 E]In-GroundPressure 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 /> `,� 1 15-IISRequired(sq. ft.) Proposed(sq.ft.) (Gals/day/sq.ft.) (Min./inch) C� Elevation <br /> VII. TANK Capaaty �� / 3' Feet $, / Feet <br /> INFORMATION in gallons Total #of 's Name Prefab. Site Con- Fiber Plastic Exper. <br /> New ExistingManufacturer <br /> Gallons Tanks Concrete Steel glass App. <br /> Tanks Tanks strutted <br /> Septic Tank or Holding Tank ❑ ❑ El 11 ❑ <br /> Lift Pump Tank/Siphon Chamber Ej ❑ 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 /> Plu er's Name:(Prin ) Plum ber',s Signature ( o tamps) MP/MPRS_W No.: Business Phone Number: <br /> PI mber'sAddress(S reet Cit ,O te,Zie): <br /> IX COUNTY/DEPARTMENT USE ONLY <br /> ❑Disapproved Sanitary Permit Fee (includes Groundwater ate ssue Issuing A ent Signature(No Stamps) <br /> *Approved ❑Owner Given Initial Surchargeree) ` <br /> Adverse Determination ���,On <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD.6398(R.05/94) DISTRIBUTION: Original to County.One copy To: Sdfety 8 Buildings Division,Owner,Plumber <br />