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Safety and Buildings Division <br /> a <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 coun /7(61 <br /> than 8 12 x 11 inches in size- eet-nl e `1 O �/U <br /> • See reverse side for instructions for completing this application State Sanitary Permit Number <br /> 30165,3 <br /> The information you provide may be used by other government agency programs ❑Check i(revision to previous application <br /> [Privacy Law,s. 15.04(1)(m)I State Plan I .Number S <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION <br /> Pr ertyOwnerName Propert Location <br /> v►A + �rS 4u� �f/4 5 /4,S T 3a( ,N, R �, W <br /> Property Owner's Mailing Address 0 Lot Number Block Number <br /> l0 9?�• l- r <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> b 4er W 1. Ski ff13 ( 1S)rU6f-178 <br /> III. TYPE OF BUILDING: (check one) ❑ State Owned ❑ Cit Nearest Road <br /> ❑ Vil age <br /> E] Public 1 or 2 FamilyDwelling- No. of bedrooms Town of�A . IN )'SO'+1 <br /> III. BUILDING USE: (If building type is public,check all that apply) Parcel TaxNumber(s) <br /> 1 ❑ Apartment/Condo OIL 3 OI OV f200 <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. p Replacement 3. ❑ Replacement of 4_ ❑ Reconnection of 5. ❑ Repair of an <br /> System E <br /> --------------------System------------------- Tank-----Only---------------Existing System---------------------Existing System <br /> ------------ <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 /> 1 1Seepage Bed 21 [:]Mound 30 E]Specify Type 41 E]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 /> V1. 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 /> do Oo . �eet 10 7 ,2S—Feet <br /> ac <br /> TANK Ca it <br /> VII. INFORMATION in gallons Total #of Manufacturer's Name Prefab Site on- Steel Fiber- Plastic Exper <br /> New Existin Gallons Tanks Concrete strutted glass App. <br /> Tanks Tanks <br /> e tk or Holding Tank Z S� VJ ,ewr ❑ ❑ 1-1 ❑ 11t Pump T k/Siphon Chamber 1 5V 4u A ,+ ❑ ❑ ❑ ❑ ❑ <br /> RESPONSIBILITY STATEMENT <br /> I,the undersigned,assume responsib lity for installation of the onsite sewage system shown on the attached plans. <br /> Plumber's Name:(Print) PI tier's Ignatur :( Stamps) MP/MPRSW No.: Business Phone Number: <br /> �JjeCSuer t saa� <br /> Plumber's t!; ss(,ewii ,City,St te,Zip d ): <br /> iq <br /> IU <br /> IX. COUNTY/ DEPARTMENT USE ONLY t J <br /> ❑Disapproved Sanitary Permit Fee (Includes Groundwater ate IssuedIssuing Agent Signature amps) <br /> proved ❑Owner Given Initial ��! O Surcharge fee) - <br /> Adverse Determination t/l � 1117 <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SHD-6398(R.W94) 10MRIBOTION: Original to CnunI ,One cu,y To: Suety 8 Huildingf Divnion,Owuer,Plumtur <br />