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_ Safety and Buildings Division <br /> 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 101 <br /> than 8 12 x 11 inches in size. <br /> State Sanitary P/mit Numb <br /> • See reverse side for instructions for completing this application <br /> 4217 <br /> The information you provide may be used by other government agency programs CC]Check it r Islion to previoug application S <br /> (Privacy Law,s. 15.04(1)(m)1. State Plan I.D.Num <br /> I. APPLICATION INFORMATION- PLEASE PRINT ALL INFORMATION <br /> Property Owner Name t Property Location C/ N, R/ E(or(NJ <br /> 41.)1/4 �� t/a,5 / T y0 r <br /> I Is Lz +t? - <br /> Property Owner's Mailing Address rr !! Lot Number Block Number <br /> :1,2 L L) / tai <br /> City, ate �Y1 Zip Code Ph/one/Number Subdivision Name or CSM Number <br /> State Owned ❑ Clty Nearest Road <br /> I. TYPE OF BUILDING: (check one) ❑ ❑ village ,4 Lae <br /> k <br /> Public 1 or 2 FamilyDwelling0-No.of bedrooms rA Town of <br /> ) <br /> III. BUILDING USE: (If building type is public,check all that apply) Parcel Tax Number(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 /> an <br /> A) 1 New 2. Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of ys <br /> ❑ Tank Only - Existing System- -----_--Existing System <br /> System System Y____________ <br /> -------- ------------------- <br /> B) ❑ A Sanitary Permit was previously issued. Permit Number Date Issued <br /> IV- TYPE <br /> . 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 /> 22❑In-Ground Pressure 42❑Pit Privy <br /> 12 Seepage Trench 43 Vault Privy <br /> 13 E]Seepage Pit <br /> 14❑System-In-Fill <br /> VI. ABSORPTION SYSTEM INFORMATION: <br /> 1.Gallons Per Day 2. Absorp.Area 13- Absorp.Area 4. Loading Rate 5. Perc. Rate 6. System Elev. Elevation 7. Final rade <br /> Required(sq.ft.) Proetposed(sq.ft.) (Gals day/sq.ft.) (Min-/inch) c Feet <br /> b e7 a a Fe99. <br /> VII. TANK Capaci Site Fiber_ Exper <br /> in gallons Total #of Manufacturer's Name Prefab Con- Steel lass Plastic App <br /> INFORMATION New Existin Gallons Tanks Concrete strutted g <br /> T nks Tanks <br /> 4eptic Tank or olid- 5 Tank. o U' 'y <br /> liftPump Tank/Siphon Chamber Ei EI El ❑ ❑ <br /> VIII. RESPONSIBILITY STATEMENT <br /> 1,the undersigned,assume responsibility for installation of the onsite sewage system shown on the attached plans. <br /> Plumber's Signature:(NoStamps) MP/MPRSWNo.: Business Phone Number: <br /> Plumber'sName:(Print) /. // // <br /> &It) le- <br /> Plumber's <br /> � O firt G�j <br /> Address(Street,City,Stale,Zip Code): <br /> IX. COUNTY/ DEPARTMENT USE ONLY <br /> ❑Disapproved Sanitary Perm) Fe li rdes ZrgGroundwater at Issuing Agent gna r ps) <br /> rcharge Fee) SV��y1 <br /> �4 1 pproved ❑Owner Given Initial <br /> Adverse Determination <br /> X. CONDITIONS OF APPROVAL/REASONS FORDISAPPROVAL: <br /> SRD-6398 RR,05/94) DISTRIBUTION: Original to County.One copy To: safety&Ruilaings Div,-ion.Owner,Plumber <br />