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ero 60y-no, <br /> Safety and Buildingsbivision <br /> ■�■w'i3 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 I <br /> /b <br /> than 8 112 x 11 inches in size. /,A')if a0 <br /> • See reverse side for instructions for completing this application State Sanitary Permit Number <br /> The information you provide maybe used by other government agency programs � ��" <br /> (Privacy Law,s- t 5.04(1)(m)]. <br /> ❑Chec revision[o previous application <br /> State Plan I.D.Number <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION I <br /> Property Owner Name Property Location <br /> P �_SoiL1 j' t/a te- 1/4,S T T_? N, Rf!� E(or <br /> Property Owner's Mailing Address Lot Number Block Number <br /> City,State Zip Code Phone Number ubdivision Name r SM um <br /> II. TYPE OF BUILDING: (check one) ❑ State Owned ❑ ItY Nea st Road <br /> Public or 2 FamilyDwelling- No. of bedrooms ❑ village o� �i�/r <br /> Town OF r �-n-'Or^.� <br /> III. BUILDING USE: (If building type is public,check all that apply)F1PNumbers/)1 /arcel Tax 3 <br /> c <br /> Apartment/Condo 8 — 3 �J— <br /> .7 70C) <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. ONew 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an <br /> ---System -------- ------------- <br /> System Tank Only- --- Exlstin System ExistingSystem <br /> stem <br /> --- -- -------- ------------gy <br /> - -------------------- ---- <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 3. 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) �+ Elev�ation <br /> Feet 9FJFeet <br /> VII. TANK Capacuty <br /> INFORMATION in gallons Total #of Manufacturer's Name Prefab. Site Fiber- Exper. <br /> New ExistingGallons Tanks Concrete Con- Steel glass Plastic APD <br /> Tanks Tanks structed <br /> Septic Tank or Holding Tank 7-5-6> El <br /> Lift Pump Tank/Siphon Chamber El 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 Na/me:(Print) / Plumber's5ignatur/e:(No Stamps) MP/MPRSW No.: Business Phone Number: <br /> Plumber's Address(Street,City;State,Zip Code): <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> E]Disapproved Sanitary Permit Fee (Includes GroundwateTV <br /> slue Issuing Agent Si nature No <br /> 1 Surcharge Fee) <br /> Approved ❑Owner Given Initial Sd� 9Adverse Determination 60r� <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398 R.05/94) DISTRIBUTION: Original to County,One copy To: Safety B Buildings Divn.ion,Owner,Plumber <br />