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Safety and Buildings Division <br /> �••Y•_�+ <br /> SANITARY PERMIT APPLICATION m Bureau of Building Water System <br /> v■�rir■ <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. e,7T <br /> • See reverse side for instructions for completing this application State Sanitary Permit Number <br /> ,;2,5';y6 q,7- <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 LD.Number <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION Syb <br /> Property Owner Napes Property Location <br /> d/'�/J/c>! /C .7,0 S_114 s� 1i4,5o2� Thy ,N, R/t'� E(or)W1 <br /> Property Owner's Mailing Address z Lot Number Block Numbed_ <br /> a sd F� ✓Lz� d 5— <br /> City,State Zip Code I Phone Number Subdivision Name or CSM Nu er <br /> II. TYPE OF BUILDING: (check one) ❑ State Owned ❑ Cit Nearest Road <br /> ❑ Vil age <br /> Public -1 or 2 FamilyDwelling-No.of bedrooms Town OF e elJuYi-� C.-c- <br /> HI. BUILDING USE: mbers) <br /> (If building type is public,check all that apply) Parcel Tax Nuvz2 <br /> 1 F1 Apartment/Condo U/6 — 3 307o — D S 5'60 <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. ❑ Replacementof 4_ ❑ Reconnectionof 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 /> NonPressurizedDistribution Pressurized Distribution Experimental Other <br /> 11 R Seepage Bed 21 (Mound 30❑Specify Type 41 [) Holding Tank <br /> 12 5Seepage 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. Pert. Rate 6. System Elev. 7. Final Grade <br /> Re uired(sq. ft.) Proposed(sq.ft.) (Gals/day/sq.ft.) (Min./inch) q Eleva�tvo )! <br /> Feet s.7*i: Feet <br /> Caci <br /> VII. TANK a tin gallons Total #Of Prefab. Site Fiber- Exper <br /> INFORMATION g Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App <br /> New Existingstrutted <br /> Tanks Tanks <br /> Septic Tank or Holding Tank Itfed {JOG' C' r ❑ ❑ ❑ ❑ ❑ <br /> t lft Pump Tank/Slphon Chamber j� 00 6Q.J ® ❑ ❑ ❑ ❑ ❑ <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 /> Plumber's Address(Street,City,State,Zip Code); <br /> IX. COUNTY/ DEPARTMENT USE ONLY <br /> E]Disapproved Sanitary Permit Fee (includes Groundwater ate lss Issuing Agent natur (No a s) <br /> loved ^ surra ge tee) <br /> 1pp ❑Owner Given Initial �l�'6 (1 M ar Z� 3� <br /> / ` Adverse Determination a+v KJ <br /> X. CONDITIONS OF APPROVAL/ REASONS FOR DISAPPROVAL: <br /> SeD-6398(a DS/94) DISTRIBUTION. Original to Counl Y.One copy To. Setety&PuIlJings Divmion,Owner,Plumber <br />