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^apo: Safety and Buildings Division <br /> �•i�iillR 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 County 1� ' y / 9 <br /> than 8 112 x 11 inches in size. ctrl7B 7T q <br /> • See reverse side for instructions for completing this application State Sanitary Permit Number <br /> , 8 7/o& <br /> The information you provide may be used by other government agency programs ❑Check if revision to previous application <br /> (Privacy Law,s. 15.04(1)(m)]. State Plan I.D. umber <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION If1 `I <br /> Property Ow er Name Property Location <br /> E `. 1/a 1/a,S °7 T ,N, R 16:11,e(or)W <br /> Property Owner's-79 Mailing Address , W I r Lot Number / Block Number <br /> City,St to Zip Code Ph ne Number Subdivision Name or CSM Num er. <br /> PA 17/nN /o ( /d)by -/6CS M �- /95 <br /> IL TYPE OF BUILDING: (check one) ❑ State Owned ❑ City Nearest Road <br /> ❑ Village �,/ / `� gig <br /> Public 1 or 2 FamilyDwelling- No.of bedrooms � town of �r,o ¢ .STA r.0 <br /> III. BUILDING USE: (If building type is public,check all that apply) Parcel TaxNumber(s) c� <br /> 1 E] Apartment/Condo ©3`7' ` JJ a 7 " 9� O <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. go New 2_ ❑ Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5. ❑ 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 ❑Seepage Bed 21 ❑Mound 30❑Specify Type 41 J,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 /> ft <br /> Required (sq.ft.) Proposed(sq.ft.) (Gals/day/sq.ft.) (Min./inch) Elevatio,n�,,\\ <br /> Feet Peet <br /> Ca aat <br /> VII in gallons Total #of MName Prefab- ionFiber- Exper <br /> INFORMATION _ <br /> New Existin Manufacturer's _ Steel <br /> Gallons Tanks Concrete strutted glass Plastic App <br /> Tanks Tanks <br /> Septic Tank or Holding Tank LO ® ❑ ❑ ❑ ❑ ❑ <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) 1 um er's ignat e:(No tam s) IW/MPRSW No.: Business Phone Number: <br /> Plumber's 11dress(Street,City,State,Zip Code): <br /> &C (,.I <br /> IX. COUNTY/ DEPARTMENT USE ONLY <br /> ❑Disapproved Sanitary P rmit Fee 0ncludesGroundwater ate IssuedIssuing Age Signat a(No to s) <br /> pproved []Owner Given Initial ��6 urcbargeFee) )�I/ g6 <br /> Adverse Determination ( / <br /> X. CONDITIONS OF APPROVAL/REASONS FO SAPPROVAL: <br /> SBD-6398(R.05/94) DISTRIBUTION: Original to County,One copy To: Safety 8 Buildings Division,Owner,Plumber <br />