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0" ' 6z)%,/ l <br /> _ Safety and Buildings Division <br /> SANITARY PERMIT APPLICATION Bureau of Building Water System <br /> 201 E.Washington Ave- <br /> In accord with ILHR B3 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 8 112 x 11 inches in size. <br /> • See reverse side for instructions for completing this application State Sanitary Permj�Num7r <br /> The information you provide may be used by other government agency programs E]CheceY�I, revlsgn to prevlou application <br /> l Privacy Law,s. 15.04(1)(m)]. State Plan I.D.Number <br /> 1. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION <br /> XIA- <br /> Property Owner Name Property Location <br /> 41/4,S /(F, T Lqo ,N, R / E (orr)D <br /> Property Owner's Mailing Addr ss Lot Numberq Block Numbe <br /> 1�Ik 6 ilii AUS / /V <br /> Ci y,State c Zip Code Phone Number Subdivision Name or CSM Number <br /> kit-- V1L� l"l'l/Idi 2 Co (�✓z >4�a o�,'�C�Ir .SI .r2� . <br /> Ill. TYPE OF BUILDING: (check one) ❑ State Owned ❑ City Nearest Road <br /> L1A1+�L,L1tia7 ,��� � <br /> Public 1 or 2 FamilyDwelling ❑ VillageUL -No.of bedrooms 3 own OF <br /> III. BUILDING USE: (if building type is public,check all that apply) Parcel TaxNumber(s) <br /> 1 ❑ Apartment/Condo I <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 /> S ❑ 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_ ❑ Replacement 3_ ❑ Replacement of 4_ E] Reconnection of 5. ❑ Repair of an <br /> ystem __ 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 Xseepage 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 /> Required (sq .ft.) Pr p sed(sq.ft.) (Gals/day/sq.ft.) (Min./inch) C� ( Elevaiiontl <br /> r —� `B'o Feet Feet <br /> Capacity VII. FORMATION in gallo s Total #of Prefab Site Fiber- Plastic Fxper <br /> Gallons Tanks Manufacturer's Name Concrete con- steel glass App. <br /> New Existin strutted <br /> Tanks Tanks <br /> Septic Tank or Holding Tank r/[i� Id�U �'.-LCL ❑ ❑ ❑ ❑ 1 ❑ <br /> Lift Pump Tank/Siphon Chamber 01)L ❑ ❑ ❑ ❑ ❑ ❑ <br /> VIII. RESPONSIBILITY STATEMENT <br /> I,the undersigned,assume responsibility for installation of the onsite sewage system shown on the attached plans. <br /> Plumbers Name:(Print) Plum u S P/MPRSW No.: Business Phone Number: <br /> Plumber's Address(Street,City,State,Zip Code). <br /> ,�) <br /> IX. COUNTY/ DEPARTMENT USE ONLY If <br /> ❑Disapproved Sanitary Permit Fie (Includes Groundwater ate ssue Issuing Agent Si A_ffZtur eS ) <br /> /56 (j/'(J Surcharge fee) <br /> pproved ❑Owner Given Initial <br /> Adverse Determination � <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SND-6398(R.OS/94) DISTRIBUTION'. Original to Cmu,ly,One Copy To: Safety 8 Buildings Division,Owner,Plwnwr <br />