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com*y <br /> SANITARY PERMIT APPLICATION Safetreauy anofd BuiBuildin yldi g WaterlS s <br /> Butem <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 8 112 x 11 inches in size. cs/ e -�D <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 programs <br /> (Privacy Law,s. 15.04(1)(m)]. <br /> ❑Check rf rewsion to previous application <br /> State Plan LD.r�rp <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION <br /> Property Owner Name / Property Location <br /> � 4✓ S'L<7 1/4 1/4,S T N, R /,�'E(o W <br /> Property O er's Mailing Address Y [5ubdivision <br /> t Number Block Number <br /> City,State Zip Code Phone Number Name or CSM Number <br /> Hod's 0II. TYPE 0F BUILDING: (check one) ❑ State Owned o r Ila a Nearest Road <br /> Public 1 or 2 Family Dwelling- No. of bedrooms Town OF cr4z/�— <br /> 111. BUILDING USE: (If building type is public,check all that apply) Parcel TaxNumber(s) / <br /> 1 r-1 Apartment/Condo G (� G' (7 7— — Q 6 <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. E] Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an <br /> ____ System _ System _ _ Tank-Only <br /> __ ---------------Existing System _Existing system <br /> B) p 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 JXSeepage 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 /> Required(sq. ft.) Proposed(sq. ft.) (Gals/day/sq.ft.) (Min./inch) Elevation <br /> 07,7 X07 <br /> 1 ''-- `�-�,3' Feet 9,7, Feet <br /> VII. TANK Capacity <br /> INFORMATION in gallons Total #of Manufacturer's Name Prefab. Site Fiber_ Exper <br /> New Existin Gallons Tanks Concrete Con- Steel glass Plastic APP - <br /> TankS Tanks strutted <br /> Septic Tank or Holding Tank jJ� ®(j / �"�-� fel 1:1 1:1 ❑ ID E]t ift Pump Tank/Siphon Chamber ❑ ❑ Ej 1:1 ❑ ❑ <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) Q Plumber's Signature:(No mps) MP/MPRSW No.: Business Phone Number: <br /> 10 <br /> fiaa� ' <br /> Plumber's Address(Street,City,State,Zip Code): , ry <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> El Disapproved nitary Permit ee (induces Groundwater ate I ue lissuing A entS nature(NQfSt ps) <br /> A roved Surcharge Fee) <br /> PP ❑Owner Given Initial 1 <br /> Adverse Determination <br /> X. CONDITIONS OF APPROVAL/ REASONS FOR DISAPPROVAL: <br /> SBD6398(R.05/94) MTRIBUTION: Original to County,One(upy To Safety&Buildings Dim;ion,Owner,Plumber <br />