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Safety and Buildings Division <br /> _-_ SANITARY PERMIT APPLICATION Bureau BuildingWaterSystem! <br /> �:'-"��""�•� 201 E.Washington Ave. <br /> a 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 MState <br /> 6 <br /> than 8 12 x 11 inches in size. <br /> 01.D.NumRber _ff, <br /> Permit <br /> • See reverse side for instructions for completing this application <br /> The information you provide may be used by other government agency programs ication <br /> [Privacy Law,S. 15.04(1)(m)I. _ ! <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION <br /> Property Owner Name Property,Location <br /> 5 1/4 1/4,5 T ,N, R 6 E(or)W <br /> Property Owner's Mailing Adores Lot Number Block Number <br /> .gVOSA M, ERWA - <br /> Cit ,State Zip Code P(,Its <br /> Nymber— G(ZES r <br /> u 0 ( t Zia <br /> y <br /> II. TYPE F UILDING: (check one) ❑ LJ Cit <br /> State Owned Lj VillaNearest Road <br /> ge 1., <br /> Public 1 or 2 FamilyDwelling-No.of bedrooms Z IgITown OFSW t5S No- <br /> Parcel Tax Number(s) <br /> III. BUILDING USE: (If building type is public,check all that apply) 33 ©1 / 00 0o^ <br /> 1 F1 Apartment/Condo <br /> � r <br /> 2 ❑ Assembly Hall 6 ❑ y g 10 Outdoor Recreational Facility <br /> Medical Facility/Nursing Home ❑ <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 /> Replacement 3. ❑ Replacement of 4. E] Reconnection of 5_ ❑ Repair of an <br /> A) 1 New 2.❑ W Tank Only <br /> Existin S stem Existin System <br /> System System ---------y-------------------g-y------------------g-- <br /> -y-------------y--------------- <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 13- 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 /> 300 5 �- ~" Feet ji 8-$S Feet <br /> Ca aut <br /> VII. TANK in a110 S TOtdl #Of Prefab. Site Fiber- plastic Exper. <br /> INFORMATION g Gallons Tanks Manufacturer's Name Concrete Con- Steel glass APP <br /> New Existin strutted <br /> Tanks Tanks ❑ ❑ <br /> Septic Tank or Holding Tank <— - <br /> Lift Pump Tank/Siphon Chamber LJ E 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) PlumberSignature:( o mps) MP/MPRSW No.: Business Phone Number: <br /> ojPkj S1 14261 l5- g66- I <br /> P mber's Address(Street,City,Stat Zip Code). <br /> 35 <br /> IX. COUNTY/ DEPARTMENTUSE ONLY <br /> El pp <br /> Sanitary Permit Fee (Includes Groundwater 7at/el IssuingA entS natu ( Stamps) <br /> '00charge Fee) tel/approved ❑Owner Given Initial /�Q /Z y� <br /> Adverse Determination <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(R.05/94) DISTRIBUTION: original to county,One copy To: Safety&Ruildinge Division,Owner,Plumber <br />