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Safe Buildings Division <br /> DO <br /> 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 Count �© <br /> than 8112 x 11 inches in size. <-_ h <br /> • See reverse side for instructions for completing this application State sanitary Permit�)umber c� <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)]- State Plan I.D.Nu er <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION <br /> Property Owner Name p Property Location <br /> e caAN-:50 1/a t/a,S Z T yCy ,N, R/Z E(or)o <br /> Property Owner's Mailing Ad ressLot Number <br /> ,p r <br /> City,State Zip Code Phone Number S a m e or C Number <br /> S/Pore. O/C-4i /hNf � `ia4 1(6ia)yya-sysd <br /> II. TYPE OF BUILDING: (check one) ❑ State Owned ❑ City Nearest <br /> Dwelling- Lr/ R,od <br /> ❑ VillagPublic 1 or2 Family No.ofbedrooms e 0� A�J ��I^ u <br /> 141 iii(o <br /> III. BUILDING USE: (If building type is public,check all that apply) Parcel TaxNumber(s) <br /> 1 E] Apartment/Condo /Z6 — -2 O� 0 <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 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 ®,Seepage 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 /> ys �' Reguired (sq.ft.) Proposed (sq.ft.) (Gals/day/sq. ft.) (MinAnch) / Elevation <br /> 6, °Y.3 41Y � �� -� ��� ` Feet 9'e,S Feet <br /> Ca act <br /> VII. INFORMATION in gallons Total #of Manufacturer's Name Prefab. Site Con- Steel Fiber- plastic Exper- <br /> New Existin Gallons Tanks Concrete strutted glass App. <br /> Tanks Tanks L <br /> Septic Tank or Holding Tank 0r�O 1/000 ��`jq � � ❑ ❑ ❑ ❑ ❑ <br /> Lift Pump Tank/Siphon Chamber I I ❑ ❑ ❑ ❑ ❑ ❑ <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 Stamps) MP/MPRSW No Business Phone Number: <br /> . <br /> Plumber's <br /> Address(Street,City,State,Zip Code):/ <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> E]Disapproved SanitaryPermjtfee (In`IudesGroundwater ate s ue Issuing Age Slg r Nc tamps) <br /> Approved ❑pwner Given Initial / �J�J su" argeFeet 7 <br /> Adverse Determination ` Jam© J/CTd'' <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(R.05/94) DISTRIBUTION: Original to County.One cony To: Safety&Buildings Division,Owner,Number <br />