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Safety and Buildings Division <br /> � riR SANITARY PERMIT APPLICATION Bureau Building water systems <br /> 201 E.Washington Ave. <br /> In accord with[LHR 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 COW4Y ao�� <br /> than 8 1/2 x 11 inches in size. Ts U(' K e <br /> • See reverse side for instructions for completing this application State SanitarPermit NN mer <br /> The information you provide may be used by other government agency programs ❑Check it r3isiYto previous9pplication <br /> [Privacy Law,s. 15.04(1)(m)). State Plan I.D.Number <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION I Sb 1;16,5� <br /> PrggertOwner Nam ( P operty Location p <br /> F'= y y t I �V a N LE iV� � �1/4 sk,/ 1/4,5 _ST 30 ,N, R <br /> Property Owner's Mailing Address Lot Number Block Number <br /> T. <br /> Cit st�aatter}(� b Zip iCode O (hoe;u ber y s Sul2divjsionCName or CSM Number <br /> D�{/ru U - yr SAF 3 J (., 0)1 J V <br /> II. TYPE FB LDING: (check.one) ❑ State Owned LJ !t� + (� Nearest Road T <br /> 3 ❑ Town W00d R. , C,oLn <br /> Public 1 or 2 FamilyDwelling- No.of bedrooms Town of <br /> III. BUILDING USE: (If building type is public,check all that apply) Parcel T''aJJx Number(s) 3 <br /> 1 E] Apartment/Condo d41 X — ?L-5b S- b L'�_ <br /> 2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Outdoor Recreati nal 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 W,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 [-]Seepage Bed 21 a11Ilound 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.) (Min./inch) p Elevation <br /> q5"( �� _3 _7 (o I , �� !S, Feet Feet <br /> VII. TANK Capacity site <br /> in gallons Total #of Manufacturer's Name Prefab Con- Steel Fiber- plastic Aper <br /> INFORMATION New Existin Gallons Tanks concrete strutted glass App. <br /> Tanks Tanks _ (� <br /> Septic Tank or HoldinEl <br /> g Tank p00 '-e `'"', <br /> I t Pum T k/Siphon Chamber <br /> VIII. RESPONSIBILITY STATEMENT <br /> I,the undersigned,assume responsi ility for installation of the onsite sewage system shown on the attached plans. <br /> Plurpb�"�me:(P Int) PI mber'sSigna ur o Stamps) MP/MPRSW No: Business Phone Number: <br /> � Z Q <br /> Plumber's Address(S reet,Ci tate,Z C de): i <br /> S I' �' <br /> IX. COUNTY/ DEPARTMENT USE ONLY <br /> ❑Disapproved Sanitary Permit Few( `Odescrovndwater ate Issue suing A e gna ur o mps) <br /> /O"1( erOr�rcharge fee) <br /> pproved ❑Owner Given Initial QQ [e7� <br /> Adverse Determination <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD6398(R.0SN4) DISTRIBUTION: original to Cour,ly.One copy To: Safety 8 Buildings Divoion,owner,Plumber <br />