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Safety and Buildings Division <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 81/2 x 11 inches in size. C <br /> • See reverse side for instructions for completing this application Staty Saniaryeermrt Number <br /> � � <br /> The information you provide maybe used by other government agency programs Check it revision to previous appbcalion <br /> IPrivacy Law,s. 15-04(1)lm)] State Plan I .Number <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION <br /> Proerty OwnerN me rope rt L cation <br /> ICK 5 4 1/4,5 <br /> Vi T N, R I' E (o W <br /> Property Owner's Mailing Address Lot Number Block Number <br /> 3l i Rt7. S u rrE ii <br /> Cit State Zip Code Pbone Num r <br /> QLS 3 (107 �� (, An"Art <br /> II. TYPE OF BUILDING: (check one) ❑ State Owned 13 CrtNparest Road <br /> Village <br /> Public A 1 or 2 Family Dwelling- No. of bedrooms Town OF <br /> HI. BUILDING USE: (If building type is public,check all that apply) Parcel TaxNumber(s) <br /> 1 ❑ Apartment/Condo D_:�v H_` 301 <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.YcY New 2 E] Replacement 3. ❑ Replacement of q E] Reconnection of 5. F] 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 �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 /> lI ,, Required (sq- ft.) Pronosed(sq.ft.) (Gals/day/sq. ft.) (Min./inch) q // Elevation <br /> X00 $�$ ��� .� IS•b Feet p .I Feet <br /> Ca acrt <br /> VII. TANK ingallons Total #of Prefab. Site Fiber- Plastic Exper <br /> INFORMATION Gallons Tanks Manufacturer's Name concrete Con- steel <br /> New ExiStin s rutted glass App. <br /> Tanks Tanks <br /> Septic Tank or Holding Tank ,`,� .�' ' El ❑ El <br /> I It Pump Tank/Siphon Chamber ❑ 13 Ej ❑ ❑ <br /> VIII. RESPONSIBILITY STATEMENT <br /> I,the undersigned, assume responsibility for installation of the onsite sewage system showr on the attached plans. <br /> Plumber's Name:(Print) Plumber's Signatur ( tamps) MP/MP SWNO.: Business Phone Num b r. <br /> (tqq RP opng 3 � i- <br /> Plumber's Add ress(Street,Gty,State,Z ip Cod ) <br /> 2 3;5- <br /> IX. COUNTY/ DEPARTMENT USE ONLY <br /> ❑Disapproved Sanitary Permit Fee II"`IOaes Grovndwaze. ate Issue s ing Agent Sign t re( oStamps) <br /> Approved <br /> E] <br /> Approved Given Initial Skchargefee) <br /> Adverse Determination C` G <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> S110-63981H.Wi DISTRIBUTION. Originein,Collntr.nnec011y To: Selety BfluiLllnys Drvuion,Owner.Plu ber <br />