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SANITARY PERMIT APPLICATION Safety and Built a SDivisi ystems <br /> l.�Lrt•rf Bureau of Buildin Water S <br /> 201 E Washington Ave. <br /> In accord with ILHR 83.05,Wis.Adm.Code P -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. <br /> • See reverse side for instructions for completing this application 5 ate Sanitary Permit Number <br /> The information you provide may be used by other government agency programs <br /> '� <br /> �/2 ❑Check it revision to previous application <br /> (Privacy Law,s. 15.04(1)(m)]. (. / w State Plan LD_Number <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION <br /> Property Owner Name Property Location <br /> I~ LE E r Qcu/J�t' sc`__1/4 t 1/4,S fq T yj N, R 14 E(or <br /> PropeOwner's M fling Address Lot Number Block Number <br /> W <br /> Cit ,State Zip Code Phone Number Subdivision Name or CSM Number <br /> I ( 2 -qlq3 <br /> II. TYPE OFBUILDING: (check one) ❑ State Owned ❑ City Nearest Road <br /> Public 1 or 2 FamilyDwelling- No. of bedrooms 3 Towa9 of SI�IISS 2-60 (,K, � . <br /> III. BUILDING USE: (If building type is public,check all that apply) Parcel Tax Number(s) <br /> 1 ❑ Apartment/Condo 1 � °'6 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 %X New 2. ❑ Replacement 3_ ❑ Replacement of q ❑ Reconnection of 5. ❑ Repair of an <br /> ------System --------System -- Tank-Only- --- Existing System Existing System <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 Seepage 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 /> l� Requi�3(sq. ft.) Firoposeed(sq. ft.) (Gals/day/sq.ft.) (Min./inch) Elevation <br /> VII. TANK ((Capacity ((�� -7 e ' 13.0 Feet .,$' Feet <br /> INFORMATION in gallons Total #of Manufacturer's Name Prefab. Site Fiber- plastic Exper. <br /> New Existing Gallons Tanks Concrete Con- steel glass App <br /> strutted <br /> Tanks Tanks ^� <br /> Septic Tank or Holding Tank 66 W W ❑ ❑ 0 Q Q <br /> Li ft Pump Tank/Siphon Chamber El 0 <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'(N Stamps) MP/MPRSW No.: Business Phone Nu be r: <br /> rctlq,en S 3 Z16 (S <br /> PI ber's Address(Street,City,State,Zip Code): <br /> IX. COUNTY/ DEPARTMENT USE ONLY <br /> ❑Disapproved Sanitary Permit Fee ('ndchdrgeFeeawater ate slue IssuingAgen ign raps) <br /> rcharge Fee) <br /> pproved ❑Owner Given Initial <br /> Adverse Determination <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> S80-6398(R.05194) DISTRIBUTION: Original N Cnunl y,One[npy To: Sufety B fluilJinys Division,Owner,Plumt2r <br />