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6 Safety and Buildings Division <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 53707-7 69 <br /> • Attach complete plans(to the county copy only)for the system,on paper not less Count a <br /> than 8 1/2 x 11 inches in size. 14 r A)� � �(Oqo (� <br /> • See reverse side for instructions for completing this application State Sanitary Permi Number <br /> -3)�&5 �J <br /> The information you provide may be used by other government agency programs ❑check it revision to previous application <br /> (Privacy Law,s. 15.04(1)(m)I. <br /> State Plan I.D.Number <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION <br /> Propert Owner 'e Property Location c� 7 p <br /> G t-0/e., 1/4 1/4,S / T✓!7 ,N, R 15—E(or)(0 <br /> Property Owner's Mailing Address Lot Number Block Number <br /> a A) e r' Z-,,4 A-;f— <br /> & <br /> — <br /> Cit ,State Zip Code Phone Number Subdivision N me or CSM Number <br /> W. -s s <br /> 11. TYPE OF BU LDING: (check one) ❑ State Owned ❑ city C 1� Nearest Road <br /> Public 1 or 2 FamilyDwelling- No.of bedrooms 0 v2ag OF T ol% Ile- of.J e <br /> III. BUILDING USE: (if buildingtype is public,check allthatapply) Parcel TaxNumber(s) <br /> 1 ❑ Apartment/Condo 0� � :7 �p <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. ❑ Replacement of q ❑ 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 gSeepage Bed 21 ❑Mound 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 /> 4/ Required (sq. ft.) Pro osed(sq.ft.) (Gals/day/sq. ft.) (Min/inch EI vation <br /> s0 Op i S' Feet <br /> acit <br /> VII. TANK in Cagallo 5 Total #OfPrefab. Site Fiber- Exper <br /> INFORMATION New Existin Gallons Tanks Manufacturer's Name Concrete con Steel glass Plastic App <br /> strutted <br /> Tanks Tanks <br /> Septic Tank or Holding Tank 3— ❑ ❑ ❑ ❑ ❑ <br /> Lift Pump Tank/Siphon Chamber I I ❑ ❑ ❑ 1 ❑ ❑ ❑ <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) Plumber's Signature: No Stamp MP/MPRSW No . Business Phone Number: <br /> �� <br /> P umbbeer's Address(Street,City,State,Zip Code): <br /> Y�O -s—/ v e—^—) e—� —5- <br /> 1 <br /> SI OUNTY/ DEPARTMENT USE ONLY <br /> ❑Disapproved Sanitary Permit Fee (induciesGroundwater Datelssue Issuin gent Signature(No Stamps) <br /> fOVed Surcharge Fee) <br /> pp ❑Owner Given Initial ��� q� <br /> Adverse Determination ,7/ (�(L <br /> X. ONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SND-6398(H-OS/94) DISTBIBUTiON: original to Cnur,ly.One corty To: Safety&BuilJings Division,Owner,Plumber <br />