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C-y� Gip <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 <br /> than 81/2 x 11 inches in size. k, k 14- <br /> iP <br /> • See reverse side for instructions for completing this application StateSa� y PeniNumber <br /> 5438 <br /> The information you provide may be used by other government agency programs� , Gheck it revision to previous application <br /> 9(Privacy Law,s. 15.04(1)(m)I. � nnn( State Planl.D-Number <br /> I. APPLICATION INFORM ION - PLEASE PRINT ALL INF MX 6Proa� Q� <br /> rtyowner Name t �po �, , Property Location <br /> J 1 S 1 iG 11 n V ° 30(/1/4 Aj 67 1/4,5 t 9 T N, R EJMX& <br /> Proper /wner'sMaili gF✓ dress I �( Ca A, tNurn erg Block Number <br /> !T! JT/�L K / r 'f <br /> ClState Zip Code one Number Subdivision Name or CSM Number <br /> wa '%e (70 7q L 10 <br /> 11. TYPEOF F BUILD( G: (check one) E] State Owned ❑ Cit, Nearest Road <br /> E] Village i h Thr <br /> Public rk 1 or 2 Family Dwelling- No. of bedrooms r <br /> III. BUILDING USE: (If building type is public,check all that apply) Parcel TaxNumber(s) <br /> 1 ❑ Apartment/Condo 103a 6:9-I l Jv <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. IsdReplacement 3. ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an <br /> System ystem 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 /> 11Seepage 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 /> VI. ABSORPTION SYSTEM INFORMATION: <br /> 1. Gallons Per Day 2. Absorp.Area 3. Absorp.Area 4. Loading Rate5. Perc. Rate 6. System Elev. 7. Final Grade <br /> ReOLJ (sq. ft.) Proposed(sq.ft.) (Gals/day/sq. ft.) (Min./inch) EI$vation <br /> 3 <br /> DO T 2 1 -7 ?0,0 Feet Feet <br /> Capacit <br /> VII. INFORMATION in allons Total #of Manufacturer's Name Prefab. Con-SiteFiber- Plastic Exper <br /> New Existin Gallons Tanks concrete strutted Steel glass App <br /> Tanks Tanks <br /> eptic Ta or Holding Tank N75 W ® ❑ ❑ ❑ ❑ ❑ <br /> Ift Pump Tank/Siphon Chamber I I ❑ ❑ ❑ ❑ ❑ ❑ <br /> VIII. RESPONSIBILITY STATEMENT <br /> I,the undersigned,assume responsibili y for installation of the onsite sewage system shown on the attached plans. <br /> PImbe is Name:(P int Plum a 's I ture:(o amps) MP/MPRSW No.: Business Phone Number: <br /> kCs o-eV rasa 6-- <br /> Plumber's Addres%j$treet, Pty,State fZip Code): ( r� r <br /> (C[ S v K ii <br /> IX. COUNTY/ DEPARTMENT USE ONLY <br /> ❑Disapproved Sanitary Permit Fee (Includes Groundwater ate ue Issuing Ag nt Signa re( amps) <br /> ®,Approved ❑Owner Given Initial f��urtnar9etee) <br /> /`�/ Adverse Determination ` 9rJ <br /> X. CONDITIONS OF APPROVAL/REASONS FOR/DISAPPROVAL: <br /> SBD-6398(II.05/94) DISTRIBUTION: Original m(nurd y,One ropy To: Surety 8 Buildings Division,Owner,Plumber <br />