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Safety and Buildings Division <br /> SANITARY PERMIT APPLICATION Bureau of Building Water Systems <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 County <br /> than 8112 x 11 inches in size. X "/"A-1 /A C_ 1 I <br /> • See reverse side for instructions for completing this application State s�i�yPermltZuumber <br /> The information you provide may be used by other government agency programs ❑Che k II revs ontoprevious application <br /> IPnvacy Law,s. 15.04(1)(m)I. State Plan I.D.Number <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION 5 <br /> Property Owner Name 11 ro ertyL c Ion <br /> t �r 4,5 a 7 T 3 N, R (or <br /> Property Owner's Mailing Address ( Lof Number Block Number <br /> City,State r Zip Code Phone Number Subdivision Name or CSM Number <br /> Z_j <br /> 11. TYPE OF BUILDING: (check one) ❑ State Owned ❑ City Nearest Road p� <br /> E Village <br /> eOF <br /> Public 1 or 2 Family Dwelling- No.of bedrooms c e_ L 1 <br /> III. BUILDING USE: (If building type is public,check all that apply) Parcel Tax Number(s) <br /> 1 ❑ Apartment/Condo <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 n New 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an <br /> System ________System ________ Tank Only_______________ExistingSystem _______ Existing System <br /> B) ❑ A Sanitary Permit was previously issued. Permit Number Date Issued <br /> V. TYPE OF SYSTEM: (Check only one) <br /> NonPressurizedDistribution Pressurized Distribution Experimental Other <br /> 11 ❑Seepage Bed 210 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� Required(sq. ft.) Proposed(sq.ft.) (Gals/day/sq. ft.) (Min./inch) Elevation <br /> 575-- 37 ti111 -2 97 9„2 Feet 00x y Feet <br /> Ca aclt <br /> VII. TANK n al Ions Total # of Prefab Site Fiber- Exper <br /> INFORMATION g Gallons Tanks Manufacturer's Name Concrete Con- steel glass Plastic App <br /> New Existin strutted <br /> Tanks Tanksli <br /> (q <br /> Septic Tank or Holding Tank Q0 /G'L7.� .iJ ❑ ElEl El ❑ <br /> Lift Pump Tank/Siphon Chamber i4o 1 1 pl)/ o IT" IIIm ❑ ❑ I ❑ I ❑ ❑ <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 Stamps) MP/MPRSW No./ Business Phone Number: <br /> Plumber's Address(Street,City,State,Zip mode): <br /> IX. COUNTY / D PARTMENT USE ONLY <br /> ❑DisapprovedSanitary Permit Fee Im°°des eroondwdler ate s e Issuing a Signa re tamps) <br /> oroved `cnargeree) <br /> il" I pp ❑Owner Given Initial �L <br /> Adverse Determination <br /> X. CONDITIONS OF APPROVAL/ REASONS FOR DISAPPROVAL: <br /> SBD-b398 IN.05194) DISTRIBUTION: Origlndl to Cnum y,One<upy To: Selely 80uild nqe 0imimn,Owner,Plumbxr <br />