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Safety and uildin s D vision <br /> SANITARY PERMIT APPLICATION Bureau 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 8 112 x 11 inches in size. — <br /> • See reverse side for instructions for completing this application State Sanitary Permit Number <br /> (0 qq <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)]. State Plan ID-Number <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION <br /> Property Owner Name Property Location yOc/ <br /> p y Sr=1/4 S� 1/4,S 0?8 T .7 N, R/,g E(or) <br /> Property Owner's Mailing Address Lot Number Block Number <br /> Q -*/ ,2 <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> ;r^e.v r. )r s�vy7� ( >�6�-8�l1 --- <br /> ll. TYPE OF BUILDING: (check one) ❑ State Owned ❑ icy Nearest Road / <br /> ❑ Village ccs i� oytJ /J/ c��oytJ d <br /> Public or 2 Family Dwelling-No.of bedrooms own of <br /> III. BUILDING USE: (If building type is public,check all that apply) Parcel TaxNumber(s) <br /> 1 ❑ Apartment/Condo <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. sRI New 2- ❑ Replacement 3. E] Replacement of 4- E] Reconnection of 5. E] Repair of an <br /> fes'System System Tank Only _ Existing System Existing System <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 WSeepage 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 /> Re wired (sq.ft.) Proposed(sq.ft.) (Galstday/sq.ft.) (Min./inch) Elevation <br /> 7 Feet y8 Feet <br /> VII. TANK Ca paelty Site <br /> in gallons Total #of Manufacturer's Name Prefab. con- Steel Fiber- plastic App. <br /> INFORMATION Gallons Tanks Concrete glass /app <br /> New Existingstrutted <br /> Tanks Tanks <br /> Septic Tank or Holding Tank g00 slo0 <br /> Lift Pump Tank/Siphon Chamber El ❑ E] 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 Name-(Print) J Plumber's Signa ure: o St m s) 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 FQe (Includes Groundwater ate s ue Issuing Agent Signat a(No a s) <br /> lD ..1 <br /> S tIVVSurcharge Fee) <br /> Approved ❑Owner Given Initial � <br /> Adverse Determination <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(R.OV94) DISTRIBUTION- original to County.one copy To: safety fL Buildings Division,owner,Plumber <br />