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_ Al (1,ya-P I <br /> Safety and Buildings Division <br /> err•r• SANITARY PERMIT APPLICATION Bureau of Building Water Systems <br /> 201 E.Washington Ave. <br /> In accord with(LHR 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 8 112 x 11 inches in size. U&Lcm <br /> • See reverse side for instructions for completing this application State Sanitar Preterrrmiitt Num er <br /> The information you provide may be used by other government agency programs ❑Chec d r ion t6 previous application <br /> (Privacy Law,s. 15.040)(m)] State Plan I.D.N tuber <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION S ' <br /> Property Owner Name Property Location <br /> $210 1/4 1/4,5 ;Z0 T q0 ,N, R E(or W <br /> Property Owner's Mailing Address Lot Number B1eek-1trvrt+ber <br /> 2312 L. I r7— <br /> C t <br /> Cit ,State I Zip Code Ph ne Number Subdivision Name or CSM Number <br /> ST_ M fJ. c )7 7 7- S 131 IA-r OF 0A L < Rn 0 1 <br /> II. TYPE OF BUILDING: (check one) ❑ State Owned City Nearest Road <br /> Public M 1 or 2 Family DwellingL] Village- No. of bedrooms Z' Town of COT(' Co . Ro )q <br /> III. BUILDING USE: (if buildingtype is public,check allthatapply) Parcel TaxNumber(s)�r <br /> 1 ❑ Apartment/Condo 6'A /O� <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 /> 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 21Mound 30 E]Specify Type 41 ❑Holding Tank <br /> 12 E]Seepage Trench 22'ln-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 /> 2w Required(sq.ft.) Proposed(sq.ft.) (Gals/day/sq.ft.) (Min./inch Q Elevation <br /> Gallons <br /> Zq Z •7 Sq-Z2- Feet 9(0.e Feet <br /> Ca rt <br /> VII ac <br /> INFORMATION in gallons Total #of Manufacturer's Name Prefab. Con- Steel Site Fiber- plastic Exper <br /> New Existing Gallons Tanks concrete strutted glass App. <br /> Tanks Tanks <br /> Septic Tank or Holding Tank TIP ❑ ❑ ❑ ❑ ❑ <br /> L ift Pump Tank/Siphon Chamber �� Soo ❑ ElEl 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 Signatu�(N ) rP/MPRSW No.: TBusiness Phone Number: <br /> umber's Address(Street,City State,zip 36 <br /> 5: W'. ,5Y893 <br /> IX. COUNTY/ DEPART ENT <br /> 77USE ONLY a 1 <br /> ❑Disapproved Sanitar Per 2 Oundwater ate ss e, ssuin Signat e <br /> S rge Fee) 1//' <br /> Approved ❑Owner Given Initial ) I / l <br /> Adverse Determination <br /> X. CONDITIONS OF APPROVAL/ REASDNS FORDISAPPROVAL: <br /> SBD-6398(R.05/94) DISTRIBUTION: Original to County.One copy To: safety&Ruildingn Division,Owner,Plumber <br />