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=Building <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 County /� Q <br /> than 8112 x 11 inches in size. 1'l F/ <br /> • See reverse side for instructions for completing this application StareSanr7 Permit Number <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)1. State Plan I.D.Number <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION <br /> ProAerlyOwned Name r Propert Location r <br /> /+ ' 1/4,S 3q T3 ,N, R !R.�{OlM1Jo <br /> Property Owner's Mailing Address Lot Number Block Number <br /> o 11, G� iQ�, -Z, <br /> City State Zip Code Phone Number Subdivision Name or CSM Number <br /> VC t� W rt S (?/ ) S <br /> II. TYPE OF BUILDING: (check one) ❑ State Owned It Nearest Road <br /> ❑ Village (( / 1/_ t Z <br /> Ej Public 1 or 2 FamilyDwelling-No.of bedrooms Town Or d� C <br /> III. BUILDING USE: (If building type is public,check all that apply) Parcel Tax Number(s) <br /> 1 ❑ Apartment/Condo S / 1S-3 0,3Z00 <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. E] Reconnection of 5. E] Repair of an <br /> System ! -System _____________ Tank Only___-_--_______ ExlstingSystem--- _-___-___ExistingSystem <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[]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 Rate 5. Perc. Rate 6. System Elev. 7. Final Grade <br /> Require �(sq. ft.) Propos d(sq.ft.) (Gals day/sq.ft.) (Min-/inch) Elevation <br /> J Feet 9G. Feet <br /> VII. TANK Capaaty Site <br /> in gallons Total #of Manufacturer's Name Prefab. Con- Steel Fiber- plastic Aper. <br /> INFORMATION New Existin Gallons Tanks concrete structed glass App- <br /> F__Tanks !F ❑ ❑ ❑ ❑ ❑ <br /> eptic Ta or Holding Tank <br /> Lift Pump Tank/Siphon Chamber El 0 El ❑ El <br /> VIII. RESPONSIBILITY STATEMENT <br /> I,the undersigned,assume responsib lity for installation of the onsite sewage system shown on the attached plans. <br /> Plumber's Na e: Print) PI mber's ignatur :( tamps) MP/MPRSW No.: Business Phone Number: <br /> (,S 7 ° <br /> Plu a 's Ad rens(Street ity,State, ip Code <br /> CJ Uj <br /> IX. COUNTY/ DEPARTMENT USE ONLY <br /> ❑Disapproved Sanitary Permit Fee (IncludesGroundwater ate ue Issuin A nt i natu o Stamps) <br /> / Surcharge Fee) �� <br /> Approved ❑Owner Given Initial �a 3 <br /> Adverse Determination <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(R.05194) DISTRIBUTION: original to County.One copy To: Safety&Buildings Divi ion.Owner,Plumber <br />