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Zaetyancl <br /> Buildin s DivJision <br /> �ti�nn SANITARY PERMIT APPLICATION Bureau of Building Water System! <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 J 1 / <br /> than 8 12 x 11 inches in size. �zt//-oC-_ "� / <br /> • See reverse side for instructions for completing this application State SanitaryP r it Nuu1mb7er <br /> IL <br /> The information you provide may be used by other government agency programs ❑check it CID <br /> revision to prevlougapplication <br /> [Privacy Law,s. 15.04(1)(m)]. State Plan I.D.Number 0 <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION I <br /> Property Owner Name Property Location r�i <br /> e ,L% 5 f�� P_ (` IVi)14 aJ 114,S TJ 8 ,N, R E(or) j? <br /> Property wner's Mailing Address / Lot Number Block Number <br /> CitytState Zip Code Phone Number Subdivision Name or CSM Number <br /> II. TYPE OF BUILDING: (check one) ❑ State Ownedity Nearest Road <br /> ElVillages / <br /> Public 1 or 2 Family Dwelling- No. of bedrooms M Town OF 1 <br /> III. BUILDING USE: (If building type is public,checkalithatapply) Parcel TaxNumber(s) <br /> 1 ❑ Apartment/Condo 00 6 _�--)�.j � / :5— <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. ❑ New 2. ZReplacement 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 /> 11 Eq 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 Elev. 7. Final Grade <br /> Required(sq. ft.) Proposed(sq.ft.) (Gals/day/sq. ft.) (Min./inch) Elevation <br /> � <br /> n /S,�5` Feet Feet <br /> Ca act <br /> VII INFORMATION in gallons Total #of Manufacturer's Name Prefab. Site Con- steel Fiber- plastic App <br /> - <br /> New Exist ng Gallons Tanks concrete strutted glass App- <br /> Tanks Tanks <br /> Septic Tank or lkl4a ng Tank (�r�Q ��/J >� ,�f C"_ ❑ ❑ ❑ ❑ ❑ <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:(Print) _ Plumber's Signature:, oSta s) MP/MPRSWNo.: Business Phone Number: <br /> Plumber's Address(Stree ,City,State,Zip Code): / _ <br /> ,6prk -_C- 5 <br /> IX. COUNTY/ DEPARTMENT USE ONLY <br /> ❑Disapproved Sanitary Permit Fee (includesGronndwater atsue ]ISsu g gent Signa re(No Stamps) <br /> roved Surcharge Fee)p ❑Owner Given Initial /� 167 <br /> l Cf� <br /> Adverse Determination ! 6 <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SUD-6398(R.05,W) DISTRIRUTION: Original to County,One(opy To: Safety&Buildings Division,Owner,Plumber <br />