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071-2 co)) <br /> tr �� 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 /> w Madison,WI 53707-7969 <br /> • Attach complete plans(to the county copy only)for the system,on paper not less County <br /> than 8112 x 11 inches in size. e— <br /> • See reverse side for instructions for completing this application State Sanitary Pe/rrm� it Number <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)]. State Plan I.D.Number <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION <br /> Property Owner Name Property Location <br /> Ar / "n Ili 1/4 1/4,S T 5,10 ,N, R 16 E(ort <br /> Property Owner's Mailing Add/r�'r�5Ts / Lot Number[� BIee4- Icer <br /> City,State. , Zip Code Phone Number Sw4d}wsi mWame or CSM Number <br /> .S"o (�/;Z )79V-&7: 6-) . �o <br /> II. TYPE BUILDING: (check one) ❑ State Owned ❑ City Nearest Road <br /> Public 1 or 2 Famil Dwellin - No.of bedrooms r� ❑ Town of rJ A,/ <br /> III. BUILDING USE: (If building type is public,check all that apply) Parcel TaxNumber(s) <br /> 1 ❑ Apartment/Condo C:�C;'0 F -;Z,"' �o l-) <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. CEI New 2_ ❑ Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an <br /> System 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 /> 11 [gSeepage 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 /> `sf 1 14Required(sq.ft.) Proposed(sq.ft.) (Gals/day/sq. ft.) (Min./inch) q�r Elevation <br /> s S/ ! f� Feet 98 3 Feet <br /> TANK Capact <br /> VII. INFORMATION in allons Total #of Manufacturer's Name Prefab- Con- Steel Site Fiber- Exper <br /> New Existin Gallons Tanks Concrete glass Plastic App <br /> Tanks Tanks / strutted <br /> Septic Tank or Holding Tank %69rQ lGtld ! ���Lc� ❑ ❑ ❑ ❑ ❑ <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 Address(Street,City,State,Zie Code): _ <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑Disapprove <br /> d Sanitary Permit Fee (includes Groundwater ate Issue ssuin Ag t Si ature am ) <br /> %,®.gpproved E]Owner Given Initial >� rJ Surcharge fee) <br /> Adverse Determination <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SOD-6399(R.05,W) DISTRIRUTION! Original to County,One copy To: Safety&Ruildings Division,Owner,Plumber <br />