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Safety and Buildings DisSon <br /> �f■��r■r■ 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 2 Count u/g �3 45� <br /> than 8 1 x 11 inches in size. <br /> • See reverse side for instructions for completing this application State Sanitary Permit Number <br /> The information you provide may be used by other government agency programs ❑Check i(re L�iou0 PPli n <br /> [Privacy Law,s. 15.04(1)(m)]. State Plan I.D.Nurnbfry <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION INrL1L <br /> Prop y Ow r Name ew Property Locationwe-w1/4,$ T ,N, R/Lt Tw <br /> Prifperty Owner's M lingAddress Lot Number Block Number <br /> C.-0 -- r_ <br /> Cit OYP <br /> Zi Code Phone Nu ber Subdivision Name or CSM Number <br /> Ll �Sg ¢ --- <br /> I. E F BUILDING: (check one) ❑ State Owned O Cit <br /> Iy Nearest Roa <br /> Public 1 or 2 FamilyDwelling- No.of bedrooms rowan OF <br /> III. BUILDING USE: (If building type is public,check all that apply) Parcel Tax Number(s) <br /> 1 ❑ Apartment/Condo 116 � 1 /� <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, t�f New 2. E] Replacement 3. E] Replacementof 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 /> 1 1 Seepage Bed 21 ❑Mound 30❑Specify Type 41 ❑Holding Tank <br /> 12Seepage Trench 22❑In-Ground Pressure 42❑Pit Privy <br /> 1 ❑Seepage Pit w 4 ❑Vault Privy <br /> 14 E] S���G ��w X �' fr l `W,,��j� <br /> VI. ABSORPTION SYSTEM INFORMATION: <br /> 1. Gallons Per Day 2. Absorp.Area 3. Absorp.Area 4. Loading Rate S. Perc. Rate 6. Syst E v. 7. Final Grade <br /> 4/ o Required(sq. ft.) Proposed(sq.ft.) (Gals/day/sq.ft.) (Min./inch) Elevation..?'$ <br /> (•f"Fj �Feet • Feet <br /> TANK Capac .— <br /> VII INFORMATION in allons Total #of Manufacturer's Name Prefab. Site Con- Steel Fiber- Plastic Exper. <br /> New Existing Gallons Tanks Concrete glass App- <br /> New <br /> Tanks strutted <br /> eptic Tan or Holding Tank <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) Plum 's ignature:(N to s MP/MPRSW No.: Business Phone Number: <br /> lu er's Ad ss(Street,City,State,Zip Code): <br /> c © -`'L C �� �5'f ��� 7/ <br /> IX. COUNTY DEPARTMENT USE ONLY <br /> E]Disapprove Sanitary Permit Fee (Induces Groundwater ate Issued Issuin A entSig ture S amps) <br /> (�� roved Lh 1 -7—</ 5u narge ree) <br /> V_ P Owner Givenlnitial _ OTS 5 <br /> Adverse Determination <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> "sl�n eleJ-6A3 e4- 9 V` re�cwfd Z elec4� A 0,0 <br /> Ia - <br /> SBD.6398(R.05/94) DISTRIBUTION: Original to.County.One cony To: Safety&Buildings Divx ion,Owner,Plumber <br />