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37L�b)f' <br /> X9=7- 11111116 Safety and Buildi gs Division <br /> lk <br /> i:i �r�i 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 �bo l� <br /> than 8 112 x 11 inches in size. a/'/I! <br /> • See reverse side for instructions for completing this application StateSanitar Permit Number <br /> The information you provide may be used b other government agency programs ��� <br /> y p y y g 9 y p 9 ❑Check if revision to previous application <br /> (Privacy Law,s- 15.04(1)(m)]. State Plan I.D.Number q <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION 1 57q6 — <br /> Pr 0 rty <br /> 76 —Prorty Owner Name Property Location <br /> e f t/4 1/4,S,3_11-- T39 .N, R/ E(orcw) <br /> Pr perty Ownvds Mailing Address L"F9emberBlock Number <br /> v r c�, Go Go t <br /> City,State I Zip Code Phone Number Subdivision Name orcSM Number <br /> II. TYPE CYF BUILDING: (check one) ❑ State Owned [] City Nearest Road <br /> Public 1 or 2 FamilyDwelling- No.of bedrooms o Town of e..vory 41, 17 a <br /> III. BUILDING USE: (If building type is public,check all that apply) Parcel TaxNumber(s) <br /> 1 ❑ Apartment/Condo 1 0/Y , <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. pReplacement 3. E] Replacement of 4. E) Reconnection of 5. E] 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 ❑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(s .ft.) Proposed(sq.ft.) (Gals/day/sq.ft.) (Min-/inch) c� Elevation <br /> A 57 U � / Feet Feet <br /> TANK Ca act <br /> VII. INFORMATION in gallons Total #of Manufacturer's Name Prefab. Site Con- steel Fiber- Exper_ <br /> Gallons Tanks Concrete glass Plastic App <br /> New Existin strutted <br /> Tanks Tanks <br /> SepticTankorHoldingTank <br /> L?Gv I ❑ ❑ ❑ ❑ ❑ <br /> Lift Pump Tank/Siphon Chamber 4) ❑ ❑ ❑ ❑ ❑ <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:(No Stamps) MP/MPRSW No.: Business Phone Number: <br /> G✓' <br /> Plumber's Address(Street,City,State,Zip Code): <br /> '6OV- --5—/y -5 <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> E]Disapproved Sanitary Permit Fee (i"dudesGrovndwater Dat ssu Issuing e i n ruremps) <br /> roved /'� « 5 eFee) <br /> 10 1 pp ❑Owner Given Initial (/ C, D �� <br /> Adverse Determination <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DI ROYAL: <br /> SBD-6396(R.05194) DISTRIBUTION: Original to County.One copy To: Safety 8 Ruildings Divnion,Owner,Plumber <br />