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Jh ctvyo <br /> Safety and Buildings Division <br /> SANITARY PERMIT APPLICATION Bureau of Building Water Systems <br /> u In accord with ILHR 83.05,Wis-Adm.Code 201 E.Washington Ave- <br /> . 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 812 x 11 inches in size. 415 <br /> • See reverse side for instructions for completing this application State Sanitary PermittNu9umbe <br /> ry <br /> The information you provide may be used by other government agency programs ❑Checkit evlsir>1t�prevlo plication <br /> (Privacy Law,s. 15.04(1)(m)] <br /> State Plan I.D.Num er <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION <br /> Prop y0wnerName S Propert Location <br /> ,1ia 1ia,S � / T�,/ N, R/ E( W <br /> Proper Owner's Mailing AA re �� Lot Number/ Block Number <br /> le G7 <br /> Cit State Zip Code Phone Number Subdivision Name or CS Number <br /> N�moNF8 �,,us - ( > �y� f INearest II. TYPE OF BUILDING: (check one) ❑ State Owned _ L] city Road <br /> ❑ Village , ., 0-Ir r <br /> ❑ Public 1 or 2 FamilyDwelling- No.of bedrooms � own of �(.-�L <br /> III. BUILDING USE: (If buildingtype ispublic,check allthatapply) Parcel TaxNumbeer�(s) / <br /> 1 F1 � <br /> Apartment/Condo ®s .9 4///r <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 online B, if applicable) <br /> A) I_ ❑ New 2. Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5_ E] Repair of an <br /> ------System --- -ystem --- -- 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 /> 1Seepage Bed 21 E]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.Area3. 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) a Elevation <br /> y �0c17 64 • CjJ-O Feet Feet <br /> VII. TANK Capacity <br /> INFORMATION in gallons Total #of Manufacturer's Name Prefab. Fiber- Plastic Exper- <br /> New Existin Gallons Tanks Concrete Con- Steel glass App <br /> strutted <br /> Tanks Tanks �)�j�Jy7 <br /> Septic Tank or Holding Tank 6 00 , 000 / t,• <br /> Lift Pump Tank/Siphon Chamber 0 11 ❑ 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 's Name:(Print) Plumb o Sta MP/MPRSW No.. Business Phone Number: <br /> Plumber's Address(Street,City,State,Zip Code): <br /> b tl <br /> IX. COUNTY/ DEPARTMENT USE ONLY <br /> ❑Disapproved Sanitary Permit Fee (Includes Groundwater Date Issued Ilssuing Agent ignature t mps) <br /> pproved [:]Owner Given Initial f Surcharge Fee) <br /> Adverse Determination /&tOr J6 <br /> X. CONDITIONS OF APPROVAL/ REASONS FOR DISAPPROVAL: <br /> S8116398(R.OS/94) DISTRIBUTION: Original to Cnunty,one<opy To. Safety 8 Buildings D,w_,on,Owner,Plumber <br />