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�7r <br /> Safety and Buildings Division <br /> SANITARY PERMIT APPLICATION Bureau of Building WaterSystemi <br /> 201 E.Washington Ave. <br /> In accord with]LHR 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 1/2 x 11 inches in size. y f� <br /> • See reverse side for instructions for completing this application State5anitar�Per it Nsmb, er <br /> The information you provide may be used by other government agency programs ❑Check it revision to previous application <br /> [Privacy Law,s. 15.04(1)(m)]. <br /> State Plan I.D.Number <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INE ORMATI N <br /> Property Owner ame Property Location �- <br /> in A(' � /(,J c�A/U.5 Ce/4 iu 1/4,S /9 T 9 ,N, R// E(or)o <br /> Property Owner'f Mailing Address s Lot Number 916cLdBunber <br /> �O Rr / C F U c, S 7 Go a %ofr� <br /> City,state Zip Code Phone Number Subdivision Name or CSM Number <br /> - <br /> II. TYPE F B DING: (check one) ❑ State Owned Icy Nearest Road <br /> ❑ Village <br /> Public or 2 FamilyDwelling-No.of bedrooms town of 04e_4; <br /> III. BUILDING SE: (If building type is public,check all that apply) /Paan el Tax Number(s) <br /> 1 ❑ Apartment/Condo ` 0 �Ofr�//�—O� <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- p ,New 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an <br /> ------System System __________ TankOnly - 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 S. Perc. Rate 6. System Elev. 7. Final Grade <br /> O O Required(sq. ft.) Proposed(sq.ft.) (Gals/day/sq.ft.) (Min./inch) Elevation <br /> 9 j Z � � `l 9"57 7 Feet 72, Feet <br /> Capac <br /> VII INFORMATION in allons Total #of Manufacturer's Name Prefab, Con- Steel Fiber- Exper <br /> Gallons Tanks Concrete glass Plastic App <br /> New Existin strutted <br /> Tanks Tanks �f <br /> Septic Tank or Holding Tank gDQ S/60 ,S Via✓ („D}. 1:1 El El 1-1 E] <br /> Lift Pump Tank/Siphon Chamber ❑ ❑ ❑ ❑ ❑ ❑ <br /> VIII. 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 /> Plum/y�er's Address l5treet,City,State,Zip Code): <br /> IX. COUNTY/ DEPARTMENT USE ONLY <br /> ❑Disapproved Sanitary Perm it Fee (Indadeseroundwater ate sue Issuing A nts natur (N Stamps) <br /> (SCA roved / Surcharge Fee)pp ❑Owner Given Initial 00 <br /> Adverse Determination <br /> 1 72 <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> 580-6398(R.05N4) DISTRIBUTION. Original m County,One mpy To: Talety 8 RuilJings Oimaion,Owner.Plumber <br />