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6h, ory zp <br /> Safety and Buildings Division <br /> SANITARY PERMIT APPLICATION Bureau of Building Water Systems <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 Count /-,'t/� /qa� <br /> than 8 1/2 x 11 inches in size. <br /> • See reverse side for instructions for completing this application State Sanitary Permit Number <br /> The information you provide may be used b other government agency programs �I� <br /> y p y y g 9 y p 9 ❑Check 11 evislDn to previous application <br /> ]Privacy Law,s- 15.04(1)(m)]. <br /> State Plan I.D.Number <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION <br /> ProperkOw er Name /`//�/ Property Location �� ( )� <br /> 1/4 1/4,SaS T c9 ,N, R E or <br /> Property Owner's Mailing Address Lot Number Block Number <br /> City,State Zip Code Phone Number Sdbdfs4sierrName or CSM Number <br /> S%/`e� �-✓.F— �"'Y8 7� ( )3Y9�.7& 023 <br /> II. TYPE OF BUILDING: (check one) ❑ State Owned ❑ City y ` Nearest Road <br /> Public E] 1 or 2 FamilyDwelling- No.of bedrooms se-Town of <br /> III. BUILDING USE: (If building type is public,check all that apply) Parcel Tax Number(s) <br /> 1 ❑ Apartment/Condo ©/2 _ yaa�- v v <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 online B, if applicable) <br /> A) 1. ❑ New 2. milleplacement 3_ ❑ Replacement of 4_ ❑ Reconnection of 5_ ❑ 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 Weepage 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./inch) Elevation <br /> 37S 8' �j� Feet 99,5 Feet <br /> TANK Ca aclt <br /> VII. INFORMATION in Ballo 5 Total #of Manufacturer's Name Prefab Con steel Fiber- plastic Exper <br /> New Existin Gallons Tanks Concrete strutted glass App <br /> Tpanks Tanks <br /> Septic Tank or Holding Tank Odd g�O S '�L✓ ❑ ❑ E] ED <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:(Pr t) Plumber's Signature: o Stamps) MP/MPRSW No.: Business Phone Number: <br /> Plumber's A&ress(Street,City,State,Zip Code): <br /> a S-1 Si /' e �� t✓ X72 <br /> IX. COUNTY/ DEPARTMENT USE ONLY <br /> ❑Disapproved Sanitary Permit Fee (includes Groundwater ate I,sue Issuing Ag ignatur No St <br /> rY/4��roVed ❑ )56—, <br /> J6 rcharge lee) 6 <br /> F`fVl! Owner Given Initial <br /> Adverse Determination <br /> X. CONDITIONS OF APPROVAL/ REASONS FOR ISAPPROVAL: <br /> SHO-6398(R.05/94) DISTRIBUTIONOriginal to county,One utPy To: Sufety&Buildings Divi ion,owner,Plumber <br />