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fety and fDivis <br /> lon <br /> SANITARY PERMIT APPLIC N Bureau201W <br /> of Building Water System <br /> E. ashington 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 8112 x 11 inches in size. iq4 1'ri-8 <br /> • See reverse side for instructions for completing this application State sanitary Permit Number <br /> The <br /> The information you provide may be used by other government agency programs ❑Check it revisiontoprevious application <br /> [Privacy Law,s. 15.04(1)(m)]. State Plan I.D.Number <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION 1 ,S1(,0 C) <br /> Pro erty er Name Pro pert Location ,�� -�, <br /> SVed 2 w1/4 'W 1/4,S Z.ZT � ,N, R ( g _E(nr <br /> Property Owner's Mailing Addfess Lot Number Block Number <br /> 1_7I `i p/n-e J-• <br /> City,St to Zip Code Phone Number Subdivision Name or CSM Number <br /> I. TYPE F BUILDING: (check one) ❑ State Owned ❑ ity Nearest Road <br /> ❑ village <br /> Public 1 or 2 FamilyDwelling-No.of bedrooms Town OF 1 -e12, <br /> III. BUILDINGUSE: (If building type is public,check all that apply) Parcel TaxNumb'�e-rr(s) <br /> 1 ❑ Apartment/Condo -s <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. g Replacement 3. ❑ Replacement of 4- ❑ Reconnection of 5. ❑ Repair of an <br /> System System - Tank Only .............Existing System __ Existing System <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 ❑Seepage Bed 210 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 /> Re uired (sq.ft.) Proposed(sq.ft-) (Gals/day/sq-fftJ (Min./inch) a Elevation <br /> v^ti� Feet bl, Feet <br /> VII. TANK Capaaty Site <br /> INFORMATION in gallons Galltons anks Manufacturer's Name co��Prefab. <br /> Con- Steel glass Plastic App, <br /> New Existin structed <br /> Tanks I Tanks <br /> etic Tanor Holding Tank x El El El 1:1n <br /> ft Pump T nk/Siphon Chamber El Q El n El <br /> VIII. RESPONSIBILITY STATEMENT — -p — <br /> I,the undersigned,assume responsi ility for installation of the onsite sewage system shown on the attached plans. <br /> Plumber's Name:(Pin t) Pumber's Signat re- oStamps) MP/MPRSW No.: Business Phone Number: <br /> ( S yJUP S7 71A_ M6--A2 <br /> Plumber's Address( reet,City State,Zip�ode)-D <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑Disapproved Sanitary Permit Fee lin`IudesGroundwa Groundwater 7;atej1SSue7/ Issu_ing Age Sign lure( 5 mps) <br /> Approved ❑Owner Given Initialrcharge Fee) <br /> Adverse Determination / <br /> X. CONDITIONS OF APPROVAL/REASONS FOR ISAPPROVAL: <br /> SBD-6398(R.05194) DISTRIBUTION: Original to Couniy,One copy To: Safety 8 Buildings Diwtion,Owner,Plumber <br />