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(4)'1 (Z <br /> Safety and Buildings D11vision <br /> SANITARY PERMIT APPLICATION Bureau of Building Water System <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 12 x 11 inches in size. <br /> • See reverse side for instructions for completing this application State Sanitary Permit Number <br /> 93715) <br /> The information you provide may be used by other government agency programs ❑Check if revision to previous application <br /> (Privacy Law,s. 15.04(1)(m)]. <br /> State Plan I.D.Number <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION I <br /> Property Owner Name Property Location <br /> MARK C Z41 : -3 1/4,S 2,�; T q0 ,N, R 16 E(or <br /> Property Owner's Mailing Address Lot Number <br /> Z06140 8R NItSOAl RD• /.E Z <br /> City,Sta e Zip Code Phone Number Subdivisio9 Name o umber <br /> EBSTM2 " 01 - S $43 (' > Re/•/6 ,0, 13-S <br /> II. TYPE OF BUILDING: (check one) ❑ State Owned ( ❑ city Nearest Road <br /> ❑ Public 1 or 2 FamilyDwelling- No.of bedrooms 4 WM Townn OF Ofd JJ� BR /vl L.501J RD. <br /> :II. BUILDING USE: (if buildingtype is public,check allthatapply) Parcel TaxNumber(s) <br /> 1 ❑ Apartment/Condo da C <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. Dq 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 K 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. 17. Final Grade <br /> Required (sq-ft.) Proposed(sq. ft_) (Gals/day/sq. ft.) (Min./inch) Elevation <br /> (pod S% CZ6`f ,-7 160,1 Feet 102.4 Feet <br /> Capact <br /> VII INFORMATION in allo s Total #of Manufacturer's Name Prefab. Con- Steel Fiber- Exper <br /> Gallons Tanks Concrete glass Plastic App <br /> New Existin strutted <br /> Tanks Tanks <br /> Septic Tank or Holding Tank 1 0 ❑ ❑ ❑ ❑ ❑ <br /> Lift Pump Tank/Siphon Chamber ❑ ❑ ❑ ❑ ❑ ❑ <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 tamps) MP/MPRSW No.: Business Phone Number: <br /> ICtfAi20 {7mz114S 3gz(o /s-g(o6- !S <br /> Plumber's Address(Street,City,State,Zipde): <br /> o w 35' Q45S5-r51< gull, SV$93 <br /> IX. COUNTY/ DEPARTMENT USE ONLY <br /> ❑Disapproved Sanitary Permit Fee (IncludesG ovndwater Fate slue Iss Agent Si n ture(No Stamps) <br /> Approved Surcharge lee) <br /> pp ❑Owner Given Initial � <br /> Adverse Determination <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD 6398(B.05194) DISTNIOU110N. Original to County,One copy To: Sefety 8 auilJingi Dim,ion,Owner,Plwnber <br />