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Safety and Buildings Division <br /> I:=grin 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 County �y�- <br /> than 8112 x 11 inches in size. —/ r � <br /> • See reverse side for instructions for completing this application State sanitary Permit Number <br /> ;2-5(4 y�eo <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 INFORMATION I �J <br /> Property Owner Name Property Location <br /> A4 t", �JQSL 1r4 N, 1/4,S :35' T 37 ,N, R )S, E(or)oN <br /> Property Owner's Mailing Address ` Lot Number Block Number <br /> 9Y� 5 v�rf y c`»-ks C.i rt./. <br /> City,State I Zip Code Phone Number Subdivision Name or CSM Number <br /> II. YPE F BUILDING: (check one) ❑ State Owned C) ity Nearest Road <br /> S- ❑ Village 7rA -c J <br /> Public 1 or 2 Famil Dwellin - No-of bedrooms Town of c� � 62. <br /> ill. BUILDING USE: (If building type is public,check all that apply) Parcel TaxNumber(s) / <br /> 1 ❑ Apartment/Condo C�7�� l S-3 <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. ENew 2- ❑ Replacement 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 F,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 /> Required(sq.ft.) Proposed(sq. ft.) (Gals/day/sq.ft.) (Min./inch) Elevation <br /> 7.5­n /0 /08,-) . Z, `1 I <br /> — q Feet 5 S y Feet <br /> Capaclt <br /> VII. FORMATION in allons Total #of Manufacturer's Name Prefab Con- Steel Fiber- Plastic Exper- <br /> New Existin Gallons Tanks Concrete strutted glass App- <br /> Tanks Tanks //4'O J rpt <br /> Septic Tank or Holding Tank 1,6C>0 / �/�' 9 13 ❑ ❑ ❑ ❑ ❑ <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 /> Plumber's <br /> Address(Street,City,State,Zip Code): <br /> )so K -S"/4>,r 5."x- e J A'-7- 7.;>_ <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑Disapproved SanitaryPermit_FeR (Includes Groundwater ate IssuedIssuing Agen Sig t Stamps) <br /> roved Surcharge Fee) <br /> ❑Owner Given Initial <br /> Adverse Determination <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(R.0"4) DISTRIBUTION: Original to County,One copy To: Safety&Buildings Division,Owner,Plumber <br />