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w„„vo Safety and Buildings ivision <br /> 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 <br /> than 8 112 x 11 inches in size. //u 72F_ <br /> • See reverse side for instructions for completing this application State S�njtgry g��it Nup�ber <br /> The information you provide may be used by other government agency programs n Check if revision to previvivo„us application <br /> [Privacy Law,s. 15.04(1)(m)I- State Plan I.D.Number,� <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION A_ <br /> Property Owner Name Property Location j <br /> 114 v4,S T yp ,N, R .S�E(or CV) <br /> Property Owner's Mailing Address l arrrhr•r !��_� �.� / Block Number <br /> /O f3//tc / C <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> II. TYPE OF BUILDING: (check one) ❑ State Owned ❑ lt� Nearest Road <br /> ❑ Vil age '"f' 1 J ] O/"C, <br /> Public 1 or 2 FamilyDwelling-No. of bedrooms -2 town of �l AJ <br /> III. BUILDINGUSE: (If building type is public,check all that apply) Parcel TaxNumber(s) <br /> 1 ❑ Apartment/Condo <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. R Replacement 3. ❑ Replacement of 4. E] Reconnection of 5. E] Repair of an <br /> -Y <br /> S stem 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 W 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 /> L� Required (sq.ft.) Proposed(sq.ft.) (Gals/day/sq.ft.) (Min./inch) q Elevation <br /> T 5 , 1�l � � `- - /6 Feet ' 7f Feet <br /> VII. TANK Capacity site <br /> in gallons Total #of Manufacturer's Name Prefab. Con- Steel Fiber- plastic INFORMATION New Existin Gallons Tanks Concrete strutted glass App- <br /> Tanks Tanks <br /> Septic Tank or Holding TankOn e, <br /> El <br /> Lift Pump Tank/Siphon Chamber 00 �00 ® ❑ ❑ ❑ 0 <br /> Vlll. 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:(No Stamps) MP/MPRSW No.: Business Phone Number: <br /> GtJ o� <br /> Plumber's Address(Street,City,State,Zip Code): <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑Disapproved Sanitary Permit Fee (includes Groundwater M <br /> e Issuing Age Signature o raps) <br /> Surcharge Fee)proved ❑Owner Given Initial � -�`� <br /> Adverse Determination <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SOD-6398(R.05/94) DISTRIBUTION: original to county.One copy To: Safety 8 Buildings Division,Owner,Plumber <br />