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00 6f"11P. <br /> M. Safety and Buildings Division <br /> -- == SANITARY PERMIT APPLICATION Bureau Building Water System! <br /> f�,•Ls•7•� 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 1/2 x 11 inches in size. `�S 7 <br /> • See reverse side for instructions for completing this application S ate Sanitary Permit tuber <br /> 30 / a Y <br /> The information you provide may be used by other government agency programs ❑Check if revision to previous application <br /> ]Privacy Law,s. 15.04(1)(m)]. State Plan I.D.Number <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION <br /> IVA- <br /> Propery Owner Name Propert Location <br /> _Sr 1/4 1/4[,S7_,3 T LJO ,N, R E(or W <br /> Prop fy Owner's Mailing Address Lot Num <br /> Q(nI4 00 . D. U b L. �R>`S <br /> C ,State Zip Code Ph ne Number Subdivision Name or CSM Number <br /> 1 . TY E Il <br /> Vi <br /> OF BUILDING: (check one) ❑ State Owned ❑ iNearest Road <br /> El age neo_ u <br /> Public Z 1 or 2 Family Dwelling-No.of bedrooms Town of jjt4j0Aj co <br /> III. BUILDINGUSE: (If building type is public,check all that apply) Parcel TaxNumber(s) <br /> 1 ❑ Apartment/Condo ©% q <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. Ig Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an <br /> System System _ _ Tank Only ____________ Existing System__ _ ___ExistingSystem <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 M Seepage Bed 21 E]Mound 30 El Specify Type 41 E]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) Elevati n <br /> 3o0 Z`t 32 �--- q3.1 Feet (c. Feet <br /> TANK Ca acit Site <br /> Fiber- <br /> Vil. INFORMATION in gallons Gallons Tal anks Manufacturer's Name Concrete con- Steel glass Plastic App- <br /> New Existin structed <br /> Ta11 <br /> nks Tanks <br /> Septic Tank or Holding Tank 0 0SKA` ❑ ❑ <br /> Lift Pump Tank/Siphon Chamber E] 1:1 1:1 ❑ El <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 mps) MP/MPRSW No.: Business Phone Numb <br /> � - S- b(,- <br /> PI mber's Address(Street,City,State,Zip ode) <br /> 3S <br /> IX. COUNTY/DEPARTM ENT U E ONLY <br /> ❑Disapproved Sanitary Permit Fee (Includes Groundwater M�7. <br /> Issuing Agent ynature a s) <br /> Surcharge Fee) <br /> Approved ❑Owner Given Initial /y <br /> Adverse Determination <br /> X. CONDITIONS OF APPROVAL/REASONS FO DISAPPROVAL: <br /> SBD.6398(R.05/94) DISTRIBUTION: Original to County,One copy To: safety&Buildings Divnion,Owner,Plumber <br />