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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 8 1/2 x 11 inches in size. d' /el <br /> Ait <br /> • See reverse side for instructions for completing this application State Sanitary Permit Number <br /> �2 $11/6-6 <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)]. G-L' State Plan I.D.Number <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION — v;2 1 5/ <br /> Property Owner Name Property Location <br /> 50140,50t4 1/4 1/4,5 T N, R I E(or <br /> Property Owner's Mailing Address Lot Number Block Number <br /> O V. <br /> Cit ,State I Zip COCLe P one Number Subdivision Name vTSM N mbgr �r <br /> ( ) !. <br /> II. TYPE-OF BUILDING: (check o e) ❑ State Owned ❑ itYage S Nearest Road <br /> p �}�+ <br /> Public 1 or 2 Famil Dwelling- No.of bedroomEl Vills Town OF abTr ( 0 <br /> III. BUILDING SE: (If building type is public,check all that apply) Parcel TaxNumber(s) c1 <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.�Replacement 3_ ❑ Replacement of 4. ❑ Reconnection of 5. E] 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 21Mound 30 C]Specify Type 41 E] Holding Tank <br /> 12 E]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 /> Required (sq. ft.) Proposed(sq.ft.) (Gals/day/sq.ft.) (Min./in h) Elevation <br /> 41 (o �,Z Feet 1Q2.q 3 Feet <br /> Ca aut Site <br /> VII. INFORMATION in gallons Total #of Manufacturer's Name Prefab. Con- steel Fiber- Plastic Exper <br /> New Existin Gallons Tanks concrete structed glass App. <br /> Tanks Tanks <br /> Septic Tank or Holding Tank ❑ ❑ ❑ ❑ ❑ <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:( Stamps) MP/MPRSW No.: Business Phone Number: <br /> cZA <br /> 3q a <br /> PI mber's Address(Street,City,State,Zi Code): <br /> Zwj36- W R Sof 8q� <br /> IX. COUNTY/ DEI LRTMFNT USE ONLY <br /> / <br /> E]Disapproved Sanitary Permit Fee (includes en <br /> roundwater ate s ue Issuing Agent Signatu (N S ps) <br /> Approved F1 Owner Given Initial j� –�� <br /> 777��� Adverse Determination <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(R.05194) DISTRIBUTION: Original to county,one copy To: Safety 8 Buildings Division,Owner,Plumber <br />