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Safety and Buildings Division <br /> 201 W.Washington Avenue <br /> SANITARY PERMIT APPLICATION P O Box 7302 <br /> *nsi11 Madison,WI 53707-7302 <br /> In accord with ILHR 83.05,Wis.Adm.Code <br /> of commerce <br />_-*_-Attach complete plans(to the county copy only)for the system,on paper not less County <br /> than 81/2 X 11 inches insize. St teSanitaryPermitNumber <br /> • reverse side for instructions for completing this application 31/6- <br /> See <br /> ❑Check if rrevious app cation <br /> Personal information you provide may be used for secondary Purposes State Plan I.D.Number <br /> [Privacy Law,s: 15.04(1)(m)]. <br /> I. APPLI ATION INFORMATION- PLEASE PRINT ALL INF RMA IONo anon ,1,0 E o <br /> Property Owner Name /4 1/4,S Z5 T 4 ,N.R 14 <br /> :SC OKW gK Lot Number Block Number <br /> Property Owner's ailing Address <br /> Z$3 Zip Code Phone Number Subdivi on Name or C Number <br /> City,State I <br /> POO � dy Nearest Road <br /> II. T ILDI G: (check one) ❑ State Owned 0 village SCA � . �{p A <br /> Town OF <br /> Public 1 or 2 Fannit Dwellin -No.of bedrooms parcel TaxNumber(s) <br /> 111. BUILDIN USE: (If building type is public,check all that apply) 02-D 4h5 01 9,00 <br /> 1 C] Apartment/Condo 10 C] outdoor Recreational Facility <br /> 2 F1 Assembly Hall 6 ❑ Medical Facility/Nursing Home 11 C] Restaurant/Bar/Dining <br /> 3 ❑ Campground 7 ❑ Merchandise:Sales/Repairs 12 ❑ Service Station/Car Wash <br /> g C] Mobile Home Park <br /> 4 ❑ Church/School 9 ❑ office/Factory t3 ❑ Other: specify <br /> 5 ❑ Hotel/Motel <br /> IV. TYPE OF PERMIT: (Check only one box on line A. Check box on line B,if applicable)Reconnection of 5. ❑ Repair of an <br /> A) 1 ❑ New 2 toflReptacement 3, ❑ Replacementof 4. ❑ Reco _System Repair _S-s_te_m_ <br /> lam" Tank Only --� y <br /> S stem �-------------------Existing ------------------ <br /> __ System ---__ -y------------------------ Date issued <br /> B) ❑ A Sanitary Permit was previously issued: Permit Number <br /> V. TYPE OF SYSTEM: (Check only one) Ex erimental Other <br /> Non-Pressurized Distribution Pressurized Distribution P 41 C]Holding Tank <br /> 11tjSeepage Bed <br /> 21 El Mound 30 Specify Type 42❑Pit Privy <br /> 12 Seepage Trench 22[1in-GroundPressure 43❑Vault Privy <br /> 13❑Seepage Pit <br /> 14❑System-In-Fill <br /> VI. ABSORPTION SYSTEM INFORMATION: EI i 'on <br /> 1.Gallons Per Day 2. Absorp.Area 3. Absorp.Ar ft 4. Loading <br /> s, Raft-)te (M n5. r/inchje Ale 6. System Elev. 7. Final Grade <br /> Feet <br /> //`� Require�(sq.ft.) Proposed(sq. ) ( ti- .� Feet <br /> U/Qo co r Exper_ <br /> Capacity Prefab. site Fiber- plastic <br /> VII. TANK in gallons Total #of Manufacturers Name con- steel lass App <br /> INFORMATION New Existin Gallons Tanks Concrete strutted g <br /> Tanks Tank ❑ ❑ ❑ ❑ ❑ <br /> Septic Tank or Holding Tank 7.� ❑ ❑ ❑ ❑ ❑ <br /> Lift Pump Tank/Siphon Chamber <br /> .50 <br /> VIII. RESPONSIBILITY STATEMENT <br /> MP/MPRSW No.. Business Phone Number: <br /> f the onsite sewage system shown on the attached plans. <br /> I,the undersigned,assume responsibility for installation o <br /> Plumber's Name:(Print) Plumber's S'ignature:(N S ps) <br /> LAA NbPKt <br /> I/ l CJS <br /> PI mber's Address(Street,Cit , tate,Zip Code): 1sq <br /> 2_ 0 <br /> IX. COUNTY/ DEPART N USE ONLY (includes <br /> Permit Fee <br /> Approved <br /> ate IssuedIssuing Agen ignat e a s <br /> C]Disapproved rge Fee) <br /> Approved ❑Owner Given Initial <br /> Adverse Determination <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DI PPROVAL: <br /> DISTRIBUTIONS Original to County.One<opY To: Safety&Buildings Division,Owner,Plumber <br /> SBD-6398(RA1/97) <br />