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Wit' rin on <br /> SANITARY PERMIT APPLICATION Safety and BuildingDr�isstems <br /> Bureau of Buildin y <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 Co i, <br /> than 8 112x 11 inches in size. A4 „ A-)-�_ ;ZO <br /> • See reverse side for instructions for completing this application State Sanitarryy}Perm Nu2mber <br /> 0 <br /> The information you provide may be used by other government agency programs ✓ <br /> [Privacy Law,s- 15.04(1)(m)]. E]Check d revision to previous application <br /> State Plan I.D.Number <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION <br /> Property Owner Name r Property Location <br /> t <br /> �/ z9 w4 ---1/4,S/9 T y-o , N, R/ E(o W <br /> Property Owner's MailingQd res5 � Lot Number Block Number <br /> City,StateZip Code Phone Number SubdiMe9n�a4ae or <br /> G/f/r ��✓� ( <br /> II. TYPE OF BUILDING: (check one) ❑ State Owned ❑ Citr Nearest oad <br /> Public 1 or 2 Famil Dwelling- No. of bedrooms Towg of Co Q e�ZJ <br /> SII. BUILDING USE: (If building type is public,check all that apply) Parcel Tax Number(s) / <br /> 1 E] Apartment/Condo Qa r // / O & Sid <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. ❑ New 2 (Replacement 3_ ❑ Replacement of 4_ ❑ Reconnection of 5. ❑ Repair of an <br /> ----- System ---- Tank Only Existing System ExistingSystem <br /> ------------------------------------------------------g-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 /> 1 1 .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 1 5. Perc. Rate 6. System Elev. 7. Final Grade <br /> / Required (sq. ft.) Proposed(sq.ft.) (Gals/day/sq. ft.) (Min./inch) Elevation <br /> (� 'fey, Feet 9'7 7 Feet <br /> VII. TANK Capacity <br /> INFORMATION in gallons Total #of Manufacturer's Name Prefab- site Fiber_ Ex <br /> New ExistingGallons Tanks Concrete Con- Steel glass Plastic APPr. <br /> Tanks Tanks strutted <br /> Septic Tank or Holding Tank 1,200 oZ00 l�J <br /> Lift Pump Tank/Siphon Chamber El El 0 0 Q ❑ <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:(Prin Plumber's Signature:(No Stamps) MP/MPRSW No.: Business Phone Number: <br /> Plumber's Address(Street,City,State Zip Code): <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑Disapproved Sanitary Permit fae (In,ludes crovndwaterIm <br /> IssuingA ent - nature <br /> 1[] is <br /> Given Initial r� /' Sur`harge Fee) <br /> ifroved <br /> Adverse Determination <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> S81>-6398(R.OV94) DISTRIBUTION: Original to Cnunty.One Copy To: Safety&Ruildings Divr ion,([wrier,PlunrWr <br /> _ i <br />