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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 �6��J <br /> than 8 112 x 11 inches in size. (G <br /> • See reverse side for instructions for completing this application State Sanitary Permit Number <br /> The information you provide may be used b other government agency programs _��IO&O3 O <br /> y p y y g 9 y p g ❑ctle�k it revision to previous application <br /> IPrivacyLaw,s- 15.04(1)(m)I. State Plan l.D.Number <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION S� — %Ko .3 <br /> Prop y O er Name PrWerty Location <br /> L�14 A,S �� T 7 ,N, R114 Ill <br /> Pro ert wner's ailing rens `I Lot Number Block Number <br /> a W • -. <br /> Cify,State . ZiCode t Prhone Number ubdivision Name or CSM Number <br /> II. TYPE OF BUILDING: (check one) ❑ State Owned ❑ City Ne st Ro d <br /> ❑ Village <br /> Public 1 or 2 FamilyDwelling- No.of bedrooms Town OF �/G` ;te, /�Lt <br /> III. BUILDING USE: (If building type is public,check allthatapply) Parcel <br /> lTTax Nummbber(s) ^7 <br /> 1 [-] Apartment/Condo 1v O r^j -�R`//e e <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. E] Reconnection of 5- F] Repair of an <br /> System System T 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 22P(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 S. Perc. Rate 6. System Elev. 7. Final Grade <br /> Req 'red ft.) Pro osed sq.ft.) (Gals/day/sq. ft.) (Min./inch) I <br /> C EI vation <br /> O ,r� Feet $ Feet <br /> TANK Ca act <br /> VII INFORMATION in gallons Total #of Manufacturer' Name Prefab. Site Con- Steel Fiber- Plastic Exper <br /> New Existin Gallons Tanks concrete strutted glass App. <br /> Tanks Tanks <br /> Septic Tank or Holding Tank ❑ ❑ ❑ ❑ ❑ <br /> Lift Pump Tank/Siphon Chamber ❑ ❑ ❑ ❑ ❑ ❑ <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) Plumb ' S- nature:(No am - MP/MPRSW No.: Business Phone Number: <br /> Plumber's Address(Street,City,State,Zip Code�� �ginz� Z i� l�l�nC <br /> IX. COUNTY/ DEPARTMENT USE ONLY <br /> ❑Disapproved Sanitary Pe mit Fe (includes Groundwater ate Issued Issuing geoll re amps) <br /> Approved I []Owner Given Initial t9 Surchargelee) <br /> Adverse Determination �r/ <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> W)-63980A 05/94) DKieIBUTION: Original w Cour.ty.One copy To: Sulety 8 Buildings Cl Owner,Plumber <br />