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nd <br /> Divis <br /> ��:�.�n SANITARY PERMIT APPLICATION Safety ofBuilldinggWaterlS stems <br /> Bureau of Building y <br /> 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 8 112 x 11 inches in size. -;?a 611.3 <br /> • See reverse side for instructions for completing this application State Sanitary P ml N ber <br /> The information you provide may be used by other government agency programs <br /> [Privacy Law,s. 15.04(1)(m)I. ❑ eck i(revision to previous application <br /> State Plan LD.NurltbRr^ <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION <br /> Property Owner Name Propert Location <br /> Wv4 1�/ v4,S � T N, R ,S E(o W <br /> Property Owner's Mailing Address Lot Number t�1eE#NusAb�r <br /> Cit State Z O ' L <br /> City Zip 00`13 (hone;umber Subdivisi�Nameori_So1�,umber <br /> E135TER Ld I . l �, 1IYY!! l <br /> II. TYPE F B ILDING: (check one) ❑ State OwnedIty earest Road <br /> Ej Public 1 or 2 FamilyDwelling-No. of bedrooms 3 E1VillageR <br /> Town OF� c-l4S0A) ICo, -Rp, A <br /> III. BUILDING USE: (If building type is public,check all that apply) Parcel Tax Number(s) <br /> 1 ❑ Apartment/Condo m 4=00 03 100 <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. I4 New 2. ❑ Replacement 3. ❑ Replacement of 4. Reconnection of <br /> System System Tank Onl ❑ 5. E] Repair of an <br /> ____________________Y_________ _ Existing S-----------------stem 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 N 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 qSD Day 2. Absorp.Area [3. Absorp.Area 4. Loading Rate 5. Perc. Rate 6. System Elev. 7. Final Grade <br /> Required (sq.ft.) Proposed(sqqlg .ft.) (Gals/ �J2y/sq. ft.) (Min-/inch) Elevation <br /> G � l• - Feet 9(o.-7 Feet <br /> VII. TANK in gallons Total #of site <br /> INFORMATION Gallons Tanks Manufacturer's Name Prefab. Con- Fiber- plastic Exper <br /> New ExistingConcrete strutted Steel glass App. <br /> Tanks Tanks <br /> Septic Tank or Holding Tank 000 1099 ( SKS ❑ ❑ ❑ ❑ ❑ <br /> Lift Pump Tank/Siphon Chamber 1-1 El E] ElVlll. RESPONSIBILITY STATEMENT <br /> El EL I,the undersigned,assume responsibility for installation of the onsite sewage system shown on the attached plans. <br /> Plumber's Name:(Print) Pfumber'sSignature:(No Stamps) MP/MPRSW No.: Business Phone Number: <br /> 3'T2j <br /> t c H Rt7 p I IS-866- �(S`1 <br /> P umbels Address(Street,city,state,Zip code <br /> S E8 x W�. 5`I893 <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑Disapproved Sanitary Permit Fee�('"y udesGroundwater ate ssue Issuing Age t S atur (N s) <br /> proved []Owner Given Initial S� !/�'r narge ree) <br /> Adverse Determination <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(R.05/)4) DISTRIBUTION: Original to county.One copy To: Safety 8 Buildings Divnion,Owner,Plumber <br />