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Safety and Buildings Division <br /> Bureau of Building Water Systems <br /> L� •���f• SANITARY PERMIT APPLICATION 201 E.Washington Ave. <br /> Vs�4�'••7 P-O-Box 7969 <br /> In accord with ILHR 83 05,Wis.Adm.Code Madison,WI 53707-7969 <br /> • Attach complete plans(to the county copy only)for the system,on paper not less rPlan <br /> 1�A <br /> than 8t2 x 11 inches in size. ermit Number _ (/ <br /> • See reverse side for instructions for completing this application on to previous application <br /> The information you provide may be used by other government agency programs Number <br /> IPrlvacy Law,s. 15.04(1)(m)I. <br /> I. APPLICATION INFORMATION PLEASE PRINT ALL INFORMATION <br /> Mperty ocation <br /> Pro rty Owner Name1/4 1/4,S Z3 T ,N, R JG E(Or)© <br /> t Lot Numbel Block Number <br /> Prop rt Owner's Mai li ng Address <br /> '> `b h1 . UL�1G vrz <br /> Zip Cod Phone Number Subd- ision Name or CS Number <br /> City,State <br /> ❑ Gty Nearest Road <br /> II. TYPE F BUILDING: (che(k one) ❑ State Owned � [] village 0� 140 co <br /> ❑ Public 1 or 2 FamilyDwelling- No.of bedrooms Parcel TaxONumber(s) <br /> M. BUILDING USE: (If building type is public,check all that apply) <br /> C:t40- <br /> 1 ❑ Apartment/Condo onal Facility <br /> 2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home Restaurant/Bar/ <br /> 1p ❑ Outdoor RecreatiDining <br /> 3 E] 11 Campground 7 ❑ Merchandise: Sales/Repairs ❑ Service station/Car Wash <br /> 4 E] Church/School 8 ❑ Mobile Home Park 12 ❑ <br /> S ❑ Hotel/Motel 9 office/Factory <br /> 13 ❑ Other: specify <br /> IV. TYPE OF PERMIT: (Check only one box on line A. Check box on line B,if applicable) Repair of a <br /> rt <br /> A) 1 r7 New 2. ❑ Replacement 3. ❑ Replacement of q_ ❑ Reconnection of 5. ❑ is . <br /> f" Tank Onl Exlstin S stem Existing System <br /> --------y-------------------g-y------------ <br /> System _System _-_-__-----_ <br /> B) ❑ A Sanitary Permit was previously issued. Permit Number <br /> Date Issued <br /> V. TYPE OF SYSTEM: (Check only one) Other <br /> Non-PressurizedDistribution Pressurized Experimental <br /> ❑Mound 30❑Specify Type 41 E]Holding <br /> Tan <br /> 11 ,Seepage Bed 21 42❑Pit Privy <br /> 12E]Seepage Trench 22❑In-Ground Pressure q3❑Vault Privy <br /> 13 E]Seepage Pit <br /> 14❑System-In-Fill <br /> VI. ABSORPTION SYSTEM INFORMATION: <br /> 1. Gallons Per Day 2- Absorp.Area 3iorp.Area 4. Loading Rate 5. Pert. Rate 6. System Elev. Elevationrade <br /> �,/� Requuirreedd(sqft) Psed(sq. ft.) (Galslday/sq. . Min. inch) cL5Feet q1-O Feet <br /> (coo ss I <br /> VII. TANK Capacity Total #of Prefab Site Fiber- plastic Exper <br /> INFORMATION n gallons Gallons Tanks Manufacturer's Name concrete con- steel glass PP <br /> New Exlstin <br /> strutted <br /> Taaxnkksss Tanks f r T ❑ ❑ El <br /> ❑ <br /> Septic Tank or Holding Tank 17rA Z^5V KIR <br /> ❑ ❑ ❑ ❑ ❑ ❑ <br /> L dt Pump Tank/Siphon Chamber <br /> VIII. RESPONSIBILITY STATEMENT <br /> I,the undersigned,assume responsibility for installation of the onsite sewage system shown on the attached plans. <br /> Plumb 's Signatur :( Stamps) MP/MPRSW No.: Business Phone Number: <br /> Plumber's Name: (Print) �y� <br /> PI mber's Address(Str t,City,State.ZipC de): <br /> IX. COUNTY/ EP RTMENT USE ONL <br /> ❑Disapproved Sanitary Permit Fee (mdudesgGroundwater ate ssue Issuing Agen Signatur (No t mp ) <br /> 5 har feel <br /> Approved ❑Owner Given Initial O /Q -c, <br /> Adverse Determination <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> DISIN19UlIt1N: Original to Couri r.nne copy to: Safety&Building,Dlmvon,Owner,Plumber <br /> SBO-6398(a 05/94) <br />