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Safety and Buildings Division <br /> v9i 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 CountyLP <br /> than 8112 x 11 inches in size. (p <br /> • See reverse side for instructions for completing this application State 31nitary Per <br /> mer <br /> The information you provide may be used by other government agency programs ❑Check it revision to previo s application <br /> [Privacy Law,s. 15.04(1)(m)]. StattP4sa l.D.Number <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION I <br /> Property Owner Name n ope yLocation <br /> t! Lck M 17#,S 3g. T YlJ r N, R /(�O— ��� <br /> Property Owner's Mailing Address Lot Number Block Number <br /> Lof <br /> Cit Stat Zip Code TFFone Number SubchVisipn ameor MNumb <br /> PE 0F BUILDING: (check one) ❑ State Owned H 't� rest Road <br /> ❑ Vil age " � �� � n n <br /> Public 1 or 2 FamilyDwelling-No.of bedrooms wn of cLK.1Q,�cr9[, <br /> III. BUILDING USE: (If building type is public,check all that apply) Parcel Tax Number(s) <br /> 1 F1 Apartment/Condo '0 _ 55, <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. �lew 2_ ❑ Replacement 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 Pressure ed Distribution Experimental Other <br /> 11 E]Seepage Bed 21 �117ound 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 SYST F ATION: <br /> 1.Gallons Per Day 2. b a 3. Absorp.Area 4. Loading Rate 5. Perc. Rate 6. System Elev. 7. Final Grade <br /> Re s Proposed(sq.ft.) (GaWday/sq. ft.) (Min./inch) �y-� cy Elevat'o <br /> 1-4 D( X = `7 / / Feet �(r} B eet <br /> Capscut <br /> VII. INFORMATION in allo s Total #of Manufacturer's Name Prefab Con Steel Fiber- plastic Exper. <br /> New Existin Gallons Tanks concrete strutted glass App. <br /> Tan06�kJ /n,� 1:11:1s0 Tanks <br /> s <br /> Septic Tank or Holding Tank / vW ❑ ❑ ❑ <br /> Lift Pump Tank/Siphon Chamber W 9001 ❑ ❑ ❑ ❑ <br /> VIII. RESPONSIBILITY STATEMENT <br /> I,the undersigned,assume responsibility for installation of the onsite se age system shown on the attached plans. <br /> Plumber's Name:(Print) Plumber's Signature:(No Stamps) P/ PRSW No.: Business Phone Number: <br /> 1r.Q e G _ �D v l S-10 <br /> Plumber'sAddress(S et ity,State,Zip Code): <br /> `�M <br /> r `0✓ <br /> IX. COUNTY/ DEPARTMENT USE ONLY <br /> ❑Disapproved Sanitary Permit Fee (IndudesGronndwater M612_�2� <br /> ssuing Age Sign ur mps) <br /> �A roved Surcharge Fee) <br /> pp ❑Owner Given Initial �����/Adverse Determination <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(R.05/94) DISTRIBUTION: Original to County,One(upy To: Safety 8 Buildings Division,Owner,Plumber <br />