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Safety and Buildings Division <br /> Bureau of Building Water Systems <br /> SANITARY PERMIT APPLICATION <br /> tt�LA� 201 E-Washington Ave. <br /> In accord with ILHR 83.05,Wis.Adm-Code P O.Box 7969 <br /> Madison,WI 53707-7969 w <br /> • Attach complete plans(to the county copy only)for the system,on paper not less County O O I <br /> than 8 112 x 11 inches in size. <br /> State Sanitary Permit Number <br /> • See reverse side for instructions for completing this application O / / M <br /> The information you provide may be used by other government agency programs ❑Checkfirto previous/application <br /> [Privacy Law,s. 15-04(1)(m)I- State Plan I.D-Numb r n <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION <br /> 4yOwne <br /> me �ropertLocation 5 T 4 &1,N, R !lp E(ortS <br /> UTzZ 7L" <br /> ailin Address Lot Number Block Number <br /> i ZIPCod Phone Number Subdivision Name or CSM NumberUILDING: (check one) ❑ State Owned ❑ city Nearest Road <br /> .*� ❑ Village 1 or 2 Famil Dwellin - No. of bedrooms �1 Town of l/ <br /> !11. BUILDINGUSE: (If building type is public,check all that apply) Parcel TaxNumber(s) _ <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 /> an <br /> A) 1 ❑ New 2 Replacement 3. E] Existin <br /> Replacement of 4. ❑ Reconnection of 5. ❑ Repair of <br /> System stem Tank-Only- ____________ ExistingSystem-__--__--- gSystem <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 1epage Bed 21 ❑Mound 30[:]Specify Type 41 ❑Holding Tank <br /> e <br /> Yk12❑]Seepage Trench 22 F1 In-Ground Pressure 42❑Pit Privy <br /> 13 E3 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 S. Perc. Rate 6. System Elev. 7. Final Grade <br /> Required(sq.ft.) Proposed(sq.ft.) (Gals/day/sq. ft.) (Min./inch) Elevation <br /> 300 G� e-1 3 r , _ �1��ifeet A914l Feet <br /> Ca aut <br /> VII. TANK in allons Total #Of Prefab Site Fiber- plastic Exper <br /> INFORMATION g Gallons Tanks Manufacturer's Name Concrete Con- steel glass APP <br /> New Existin strutted <br /> Tanks Tanks <br /> Septic Tank or Holding Tank 7 _v�' ❑ El El 1 El Pump Tank/Siphon Chamber <br /> Vill. RESPONSIBILITY STATEMENT <br /> I,the undersigned,assume responsibility for installation of the onsite sewage system shown on the attached plans. <br /> Plum 's Name:(Print) Plumber' re:( tamps SW No.: Bu ;ness Phone Number: <br /> DNA 1: 7t <br /> Plumber's Address(Street,City,State,Zip Code).-71 <br /> IX. COUNTY/ DEPARTMENT USE ONLY <br /> ❑Disapproved Sanitary Permit Fee (IndudesGroundwa[er ate Issue Issuing A en Ignature( amps) <br /> / urcharge ree) G�fp <br /> gApproved [:]Owner Given Initial � <br /> Adverse Determination <br /> X. CONDITIONS OF APPROVAL/REASONS FOR_DISAPPROVAL: <br /> Sefd�c `� 4�TQc� /- e <br /> S8n-6398(It.05194) DIST'BIBOTION: Original to County,One coPy.To: Safety 8 RuilAings Ill on,Owner,Pl u mtxr <br />