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Safety and Buildings Division <br /> rt►�i�r�n 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 8 12 x 11 inches in size. �� G <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 programs36/�c'a <br /> (Privacy Law,s. 15.04(1)(m)]. <br /> ❑Check i(revision o previous apple tion <br /> State Plan I.D.Number <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION <br /> Property Owner Name �^ Property Location <br /> k3AP_ h C, 1SGS 64,,4P76Z3 9r5 -3& T410 rNrR 15�4(or)W <br /> Property Owner's Mailing Address Lot Number <br /> 7/0 S?eG 4Block Number <br /> /) u, � <br /> City,StateZip Code Phone;umber SM Number <br /> 44 !00 Z S <br /> II. TYPE OF BUILDING: (check one) ❑ State Owned ❑ City Nearest Road <br /> Public 1 or 2 Family Dwelling- No.of bedrooms ❑ village <br /> own OF \y4o<5p <br /> III. BUILDING USE: (If building type is public,check all that apply) Parcel Tax Number(ss))/�' / /� <br /> 1 E] Apartment/Condo i ! 43 6o � 6 V <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. Ik4ew 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 ❑Se page Bed 21 E]Mound 30 E]Specify Type 41 E] Holding Tank <br /> 12 page Trench 22❑In-Ground Pressure / 42 F]Pit Privy <br /> 13 E]Seepage Pit /_ i e wt e 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 /> 4�j Required (sq.ft.) Proposed(sq.ft.) (Gals/day/sq.ft.) (Min./inch) Elevation <br /> " 156o,3 5-7"? • 8 9&-0 Feet /00�99 Feet <br /> VII. TANK Capacity <br /> INFORMATION in gallons Total #of Manufacturer's Name Prefab. S"e Fiber_ Exper. <br /> New Existin Gallons Tanks Concrete Con- Steel glass Plastic App, <br /> Tanks Tanks <br /> strutted <br /> Septic Tank or Holding Tank 1000 1 "1 Er I E] 1:1 E] E] ❑ <br /> Lift Pump Tank/Siphon Chamber (000 El El El El <br /> VIII. RESPONSIBILITY STATEMENT <br /> I,the undersigned,assume responsi ility for installation of the onsite sewage system shown on the attached plans. <br /> Plumber's Name:(Print) u I <br /> ber'sSignature N St mps) MP/MPRSWNo.: Business Phone Number: <br /> 06, <br /> � r 7eq - `1 �0 � '11s -,.3 N- 03Adbess(Stmt,City,Stata„ZP Code � O( I, / 6yIX. COUNTYC//RDEPJCAGIR)TMTLrEEN USE ONLY/ v <br /> ❑Disapproved Sa nitary Permit Fee (mdudes Groundwater ate IssuedIssuing g Signa r ps) <br /> pproveCl Surcharge f ee) <br /> ❑Owner Given Initial l �, p <br /> Adverse Determination ! �e'/mss— <br /> X. CONDITIO/Ni OF APPROVAL,/REASONS FOR DISAPPROVAL: <br /> S8D-6398(R.05/94) ` r / / DISTRIBUTION: Original to County,one copy To: Safety&Buildings Division,Owner,Plumber <br />