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tia ■ter• Safety andBuildingsDiviSion <br /> �tnn SANITARY PERMIT APPLICATION Bureau of Building Water Systems <br /> In accord with ILHR 83 05,Wis.Adm.Code 201 E.Washington Ave. <br /> 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 vi x 11 inches in size. /,-)C1I& <br /> • See reverse side for instructions for completing this application state sa_n)ltary <br /> Perm , ber <br /> The information you provide may be used by other government agency programs l � (� <br /> (Privacy Law,s. 1 5.04(1)(m)). E]Check it revision to previous application <br /> State Plan I.D.N_;Vlfr <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION <br /> Property Owner Name Property Location <br /> :KALP14 E I C jtT6r4 1/4 1 'S 'I T N, R t5 E(or W <br /> Property Owner's Mailing Address Lot Number Block Number <br /> Z 02C aG <br /> V <br /> City,State ip Code Phone Number Subdivi on;ameorCSM,Number <br /> DRao 3 ( (z <br /> H. TYPE F BUILDck one) ❑ State Owned ❑ cit Nearest Road <br /> Public 1 or 2 Famil Dwellin - No.of bedrooms Z ❑ vil age M <br /> Ef Town OF <br /> III. BUILDING USE: (If building type is public,check all that apply) Parcel TaxNumber(s) � <br /> 1 E] Apartment/Condo I (I f �O 7t) —b3- / <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. 0 5 stem New 2. E] Replacement 3. E] Replacement of 4. [:] Reconnection of 5- ED Repair of an <br /> -------yystem ----- --System----- --- - Tank Only Exlstlngy <br /> S stem ExistingSystem <br /> stem <br /> ----------------- - -------------------- ---- <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 --I Seepage Bed 21 [:1Mound 30[-]Specify Type 41 ❑Holding Tank <br /> 12 jg� eepage 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 /> 300 Requireq. ft.) Proposed(sq.ft.) (Gals/day/sq. (Min./inch) E evation� q . <br /> Feet <br /> l 17.0 Feet <br /> VII. TANK Capacity <br /> INFORMATION in gallons Total #of Manufacturer's Name Prefab. Site Fiber_ Exper <br /> New Existing Gall Ons Tanks Concrete Con- Steel Plastic p <br /> Tanks Tanks strutted glass App. <br /> Septic Tank or Holding Tank ^ G ❑ ❑ ❑ <br /> Lift Pump Tank/Siphon Chamber D El 0 ❑ ❑ ❑ <br /> Vlll. 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 ;(NCamps) MP/MPRSW No.: Business Phone Number: <br /> 3��b S-7 <br /> PI mber's Address(Street,City,Itate,Zip Code): <br /> 2,-7_760 w W]• SqS13 <br /> IX. COUNTY/DEPA TM NT USE ONLY <br /> 2i ❑Disapproved Sanitary Permit Fee (indvde, Fee)water ate ssue Iss ng gent Si ore(No Stamps) <br /> roved Surcharge Fee) <br /> PP ❑Owner Given Initial <br /> Adverse Determination <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SRD-6398(R.05194) DISTRIBUTION: Original to County,One copy To: Safety 8 Buildings Divmion,Owner,Plumber <br />