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V)^ <br /> SafetyandBuildings ivision <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 Count Y <br /> than 8 1/2 x 11 inches in size. (D 7 <br /> • See reverse side for instructions for completing this application state anitarrmit Nurpbpr <br /> The information you provide may be used by other government agency programs E]Chec3it revision to previous/application <br /> IPrivacyLaw,s- 15.04(1)(m))_ <br /> State Plan I.D.Num <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION <br /> Property Owner Name Property LocationS 3 T 37 ,N, R — "'ti.% <br /> Property O ner's Mailing Acibress / 1 Lot N b¢r e� , Block Number <br /> C ty,State Zip Code Phone Number Subdivision Nam or CSM Number <br /> 14-S&V Ir <br /> II. TYPE OF BUILDING: (check one) ❑ State Owned ❑ City Nearest RoadVil age <br /> h�E] Public X 1 or 2 Family Dwelling- No of bedrooms O TOwnn OF ��� Ski I50+'\ h F <br /> III. BUILDING USE: (if building type is public,check all that apply) Parcel TaxNumber(s) <br /> 1 ❑ Apartment/Condo 1.5-341 02, <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 online B, if applicable) <br /> A) 1. ❑ New 2. X Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5_ ❑ Repair of an <br /> System Tank Only Existing System Existing System <br /> --------------------System-------------------- <br /> ------------------------------------------- <br /> ------------ <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 JKSeepage 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.) Proposed (sq.ft.) (Gals/day/sq. ft.) (Min./inch Elevation <br /> 300 Z �3Z C 10 , Feet [OS,LSeet <br /> TANK Ca acit <br /> VII INFORMATION in gallons Total #of Manufacturer's Name Prefab. Con- Steel Site Fiber- Exper <br /> Gallons Tanks concrete glass Plastic App <br /> New Existingstructed <br /> Tanks Tanks <br /> Se ti Tank)I,r Holding Tank loop ❑ ❑ ❑ ❑ ❑ <br /> Lift Pump - nk/Siphon Chamber 1�. ® - ❑ ❑ ❑ ❑ ❑ <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) P mber'sSign tur (No Stamps) MP/MPRSWNo.: Business <br /> sPl� <br /> Phone Number: <br /> p <br /> Plumber's Address(Street,City,State,Zip Code): �a <br /> " .' <br /> IX. COUNTY/ DEPARTMENT USE ONLY <br /> ❑Disapproved Sanitary Permit Fee (Includes Groundwater ate IQ4ssuing Agent. natur (N t <br /> urcharge Fee) <br /> �kpproved ❑Owner Given Initial <br /> Adverse Determination �Ja'1 <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SKI)6398(R.W94) DISTRIBUTION'. Original io Counl y,One copy To: Sefety 8 fluildings Division,Owner,Plum Fxr <br />