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Wa ��c:-zr , <br /> Safety and Buildings Division <br /> rti�Fi rl"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 �� � <br /> than 8 112 x 11 inches in size. <br /> • See reverse side for instructions for completing this application Sirate Sanitary Perm;t Nymber <br /> The information you provide may be used by other government agency programs ❑check it rewsie�o/pre/vv/�ousap�tion <br /> (Privacy Law,s. 15.04(1)(m)]. <br /> State Plan I.D.Number <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION <br /> Propert Owner Name Property Location <br /> 1/4 1/4,S T l�( N, R 15 E(or <br /> Property Own 's Mailing Address Lot Number ,$]prlt-Myw�ber <br /> 117-0 5 .L. I <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> nl. 55033 ( S 4S&-3?17 0t_. $•4 g02-5-5 <br /> II. TYPE OF BUILDING: (check one) ❑ State Owned ❑ city Nearest Road <br /> Public Aa 1 or 2 Family Dwelling- No.of bedrooms 3 ❑ village W 55 <br /> Town OF <br /> III. BUILDING USE: (If building type is public,check all that apply) Parcel TaxNumber(s) <br /> 1 ❑ Apartment/Condo biz 5209 03 100 <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_ t71 Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an <br /> ------System --- System --- - - Tank Only - Existing S <br /> ------------- gstem_yExisting 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 X 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.) Propos(sq. ft.) (Gall ay/sq.ft.) (Min/inch) Elevation <br /> ((�o� r— - 5 • 9 Feet Q. 6 Feet <br /> VII. TANK Capacity <br /> INFORMATION in gallons Total #of Manufacturer's Name Prefab. Site Fiber- Exper <br /> New Exist ng Gallons Tanks Concrete C°" Steel glass Plastic App <br /> Tanks Tanks <br /> structed <br /> Septic Tank or Holding Tank 000 �^ 000 (�� ® 1 El 1:1 1 M I El ❑ <br /> Lift Pump Tank/Siphon Chamber El I El 1 01 ❑ IEl Ej <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:(No5 mps) MP/MPRSW No.: Business Phone Number: <br /> rc O o IfS 7-6 <br /> Plu ber's Address(Street,city,state, Code). <br /> 2.? (o S �1 <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑Disapproved Sanitary Permit Fee (IndudesGroundwmer Date Issued Issuing Age Signal re St ps) <br /> Approved El Owner Given Initial / Surcharge fee) <br /> Adverse Determination <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SHD-6398(R.OSN4) DISTRIBUTION. Original to County.One copy To: Safety&Buildings Division,Owner,Plumber <br />