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- Safety and Buildings Division <br /> Ale..:�'W::n 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 <br /> than 8 12 x 11 inches in size. J (� <br /> • See reverse side for instructions for completing this application State Sanitary rrmit Number- <br /> The information you provide may be used by other government agency programs ❑Check ilsionY6•p-reJvrious application <br /> [Privacy Law,s. 15.04(1)(m)]. State Plan I.D.Ntuber <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION <br /> Prop yOwner ame P operty cation 3 <br /> ���� 4�f�ggg6� li7a- -91af T SSG ,N, fj�b E(or <br /> Property Owner's Mailing Address / 4 / Lot No Block Number <br /> W/ <br /> y Zi Code Phone Number Subdivision Name or CSM Number <br /> City, /�Zd <br /> �g� 3 ( ) r <br /> II. TYPEOFBUILDING: (check one) ❑ State Owned o it l� L/ n Nearest Road <br /> age <br /> El <br /> p i9 .Jd .Coic)Nct /� <br /> ElPublic 1 or 2 Family Dwelling- No.of bedrooms Town OF <br /> III. BUILDING USE: (If building type is public,check all that apply) Parcel TaxNumber(s) <br /> 1 ❑ Apartment/Condo <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 S2411eplacement 3. ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an <br /> System `System Tank Only - Existing System -- Exl----System <br /> ---------- sting--------------------------------------------- <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 /> I 1 ❑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 /> VL ABSORPTION SYSTEM INFORMATION: <br /> 1. Gallons Per Day 2. Absorp.Area 13. 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) El ti <br /> 375-- -7�5� /� 9f, 3 Feetil Feet <br /> VII. TANK Capacity <br /> in gallons Total #of Manufacturers Name Prefab ConExper. <br /> - Steel Fiber- Plastic <br /> INFORMATION New Existing Gallons Tanks Concrete strutted glass App. <br /> Tanks Tanks ❑ El [1 ❑ <br /> Septic Tank or Holding Tank (�©G2 e9�� <br /> t Oft Pump Tank/Siphon Chamber do ©L� El El <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 <br /> Signature:(No St ps) MP/MPRSWNo: Business Phone Number <br /> �-/ ��� <br /> 44) <br /> Plumber's Address(Street,City,State,Zip Code: <br /> IX. COUNTY/ DEPARTMENT USE ONLY <br /> ❑Disapproved Sanitary Permit Fee (in`ludeseroondwater ate Issue Issuing Agent Signa re(N St ps) <br /> ,� -, Surcharge lee) �� 4 <br /> pproved ❑Owner Given Initial s�(C(YC<) / (J9 <br /> Adverse Determination <br /> X. CONDITIONS OF APPROVAL/ REASONS FOR DISAPPROVAL: <br /> '\ SRD-6398(R.05/94) DMRIRUTIDN origina Ito county,one copy To: Safety B Ruildiru3>DOvi lOn,Owner,Plumber <br />