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o�)_Z c > <br /> E <br /> Safety and Buildings Division <br /> �LA�1 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 8 1/2 x 11 inches in size. k y -f-- <br /> • See reverse side for instructions for completing this application state Sanitar Per it Num er <br /> The information you provide maybe used b other overnmenta enc programs !f ?O 3 <br /> Y P Y Y 9 agency P 9 ❑Check it revislDn to previo s application 71 <br /> [Privacy Law,s. 15.04(i)(m)I. State Plan I.D.Number <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION <br /> Property Owner Name Property Location <br /> t't (:�, v h1 til/4 SLC/l/4,S T ,N, R 17 &Jerlo <br /> Property Owner's Mailing Address Lot Number Block Number <br /> SVZ, LL) �S <br /> Cit ,State Zip Code Phone Number Subdivision Name or CSM Number <br /> i ( ( 2 <br /> . TYPE OF B ILDINl (check one) ❑ State Owned E] City Nearest Road /I <br /> ❑ ge Ddv11e S 1516 do <br /> Public 1 or 2 FamilyDwelling- No.of bedrooms ToToawn OF <br /> III. BUILDING USE: (if bulldingtypeispublic,check allthatapply) Parcel TaxNumber(s) <br /> 1 ❑ Apartment/Condo Oo <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. K New 2_ ❑ Replacement 3. ❑ Replacement of 4- ❑ 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 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 /> SD Require (sq. ft.) Pr po ed (sq_ft.) (Gals/day/sq.ft.) (Min./i ch) Elevation <br /> 3 • c1:5' Feet q Feet <br /> VII. TANK Capacity <br /> in gallons Total #of Prefab Site Fiber- Exper <br /> INFORMATION New Existin Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App <br /> strutted <br /> Tanks Tanks <br /> "I <br /> Tank r Holding Tank I Il000 .,eY CK 0 n <br /> Lift Pump Tank/Siphon Chamber 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) Plu ber's Signatu e: Stamps) MP/MPRSW No.: Business Phone Number: <br /> (S <br /> lumber'sAddress(Street,�ity,State Lip <br /> / <br /> �6Zt k <br /> IX. COUNTY/ DEPARTMENT USE ONLY <br /> ❑Disapproved Sanitary Pe mrt F e (IncludesGroundwaler ate slue Issuing A ent S gnatur IN s <br /> Agj�ftproved [-]Owner Given Initial J� svrtnar9eree> ` I <br /> Adverse Determination - / <br /> X. CONDITIONS OF APPROVAL/ REASONS FOR SAPPROVAL: <br /> SHU-6398(R.W94) DISTRIBUTION: Original to County,One copy To: Safety 8 Roil,ings Dw..ion,Owner,Pluint., <br />