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Safety C�� , <br /> SANITARY PERMIT APPLICATION Safety and Building <br /> dl g WaterlS stems <br /> Bureau of Buildln y <br /> r 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 O <br /> than 8 1/2 x 11 inches in size. <br /> • See reverse side for instructions for completing this application State Sanitary Permit umber <br /> cl <br /> IPnvacy Law,s 15.04(1)(m)]. <br /> The information you provide maybe used by other government agency programs ❑ChecSao 6 3k it revision to prey us application <br /> State Plan LD.Number <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION A* <br /> Propert wner Name Property Location <br /> 1/4 1/4,S 2q T ,N, R S E (or) <br /> Property Owner's Mailing Ad ress Lot Number <br /> 116&ZgL2 IML L - •3 L. <br /> City,State ZI Code Phone Number Subdivisi Name r SM umber <br /> 31 <br /> ( 2 -00 1VOL . P. 33 <br /> . TYPE BUILDI : (check one) ❑ State Owned o C llage Nearest Road <br /> E] Public 1 or 2 FamilyDwelling- No. of bedrooms own OFS CKSO 54NO Lk� D. <br /> !!I. BUILDING USE: (If building type is public,checkallthatapply) Parcel TaxNumber(s) <br /> 1 ❑ Apartment/Condo 017— 7707 90L <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 q ❑ Reconnection of 5. ❑ 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 /> 1 1V Seepage Bed 21 ❑Mound 30❑Specify Type 41 ❑Holding Tank <br /> 1 2/tj 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 /> Req iredd(sq- ft.) Pro os�(sq-ft.) (Gal ay/sq.ft.) (Min./inch) 9� 7 Elevation <br /> ^—� Feet 619. 2— Feet <br /> Capacit <br /> VII. FORMATION in allons Total #of Manufacturer's Name Prefab con- Fiber- Plastic Exper <br /> New Existln Gallons Tanks Concrete Steel glass App <br /> strutted <br /> Tanks Tanks <br /> Septic Tank or Holding Tank L000 I 5KAill 10 ❑ ❑ El E] El <br /> Lift Pump Tank/Siphon Chamber 1:1 El Ej El Q <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 Sig nature:(N St ps) MP/MPRSW No.: Business Phone Numb r: <br /> 1cNARn 7(0 - &• (57 <br /> Plumber's Address(Street,City, te,Zip Code): <br /> Z- 5 W99SM9W• 83 <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> CCC���,, <br /> E]Disapproved Sanitary Permit Fee (includes Groundwater ate slue IssuingA a Signature(No amps) <br /> i A roved /J6.Surcharge Fee) ��2/ <br /> —\pp ❑Owner Given Initial r/ t/ <br /> Adverse Determination <br /> X. CONDITIONS OF APPROVAL/ REASONS FOR DISAPPROVAL: <br /> SND-6398(R.05/94) DISTRIBUTION. Original to county,One copy'ro: Safety&RuilJing>Divr ion,Owner,Plwntkr <br />