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Safety and Buildings Division <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 County �� <br /> than 81/2 x 11 inches in size. <br /> • See reverse side for instructions for completing this application STate SanittaaalyPermit Number <br /> The information you provide may be used by other government agency programs ❑Cff r—eviSior reels application <br /> [Privacy Law,s. 15-04(1)(m)1. <br /> 41 <br /> State Plan I.D.Number <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION I <br /> Property Owner Name Property Location <br /> 114 1/4,S T 3$ ,N, R 1$ E(or)(0 <br /> Property Owners Maili Address Lot Number <br /> o2n RK ( o�• L. <br /> City State ZI Code P ne Number Subdivision Name or C5 <br /> S-1 fAUL , M N- 9S i 1 16D (� Num <br /> 1 Z)(0V- Roto <br /> II. TYPE OF B ILDING: (check one) ❑ State Owned o City Nearest Road <br /> Public 1 or 2 Famil Dwellin -No.of bedrooms 2 o To wn ageOF 90. <br /> To <br /> III. BUILDING USE: (If building type is public,check all that apply) Parcel TaxNumbeer(s) <br /> E] L <br /> 1 Apartment/Condo r _,:9NC oo <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. Replacement 3_ E] Replacementof 4- ❑ Reconnection of 5. E] 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 Oseepage 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.) (MinAnch) Elevation <br /> 3©O 'Z Z . 7 q4, g Feet •3 Feet <br /> VII. TANK Capacity <br /> INFORMATION Site <br /> in gallons Total #of Manufacturer's Name Prefab. Con- Fiber- plastic Exper. <br /> New Existin Gallons Tanks Concrete Steel glass App <br /> strutted <br /> Tanks Tanks <br /> Septic Tank or Holding Tank ❑ 1:1 1:1 ❑ ElLift Pump Tank ew D ❑ ❑ ❑ <br /> VIII. RESPONSIBILITY STATEMENT <br /> 1,the undersigned,assume responsibility for installation of the onsite sewage system shown on the attached plans. <br /> Name:(Print) Plumber's Signature: No amps) MP/MPRSWNo.: Ns_- <br /> Plumber'sss Phone Number: <br /> L qZG $(o6- /S7 <br /> Plumber's Address(Stre t,City,State, i Code): IF <br /> 2? 6 b w 35 /WJW (A)/ 5 <br /> IX. COUNTY/ DEPARTMENT USE ONLY <br /> E]Disapprove <br /> Sanitary Perry) (�rludesGroundwa[er ate ss a Issuing a Sig tur PS) <br /> approved ❑Owner Given Initial / J charge res) <br /> Adverse Determination <br /> X. CONDITIONS OF APPROVAL/REASONS FOlt DISAPPROVAL: <br /> SBD-6398(R.05/94) DISTRIBUTION: Original to Counly.One copy To: Safety&Buildings Dimion,Owner,Plumber <br />