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Safety and Buildings Division <br /> SANITARY PERMIT APPLICATION Bureau of Building Water Systems <br /> In accord with ILHR 83 05,Wis-Adm.Code P.O E.Washington Ave. <br /> 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 8 112 x 11 inches in size. u, o 3-30 <br /> • See reverse side for instructions for completing this application State Sanitary�rprt rvy��r C <br /> The information you provide may be used by other government agency programs PG ❑Check it r(e{v/si(s(((iGoJJJo to previods application <br /> (Privacy Law,s. 15.04(1)(m)]. / � State Plan I.D.Nym}�er v� <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION I �IVI F/T� O <br /> Property Ower Name � Property Location d <br /> S JalvoC ----1/4 -1/a,s D T �� ,N, Rl/g(or)W <br /> Property Owner's Mailing Address �n f Q -{ a Lot Number Block Number <br /> J <br /> Citytate bu 1 [ZjLde g30 1 Phone Number Subdivision Name or CSM Number <br /> 1 6 � <br /> II. TYPE F B ILDING: (check one) ❑ State Owned nit� -}y-- Nearest Road <br /> El Public 1 or 2 FamilyDwelling-No. of bedrooms ° Vil age �O// <br /> own OF D �g <br /> III. BUILDING USE: (If buildingtype ispublic,check allthatapply) Parcel TaxNumber(s) <br /> 1 ❑ Apartment/Condo I Qmpo(710 Day 671 00 <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. E] New 2Replacement 3. [:] Replacement of 4. [:] Reconnection of 5. ❑ Repair of an <br /> ------System ---------System - - - Tank Only---------------Existin 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,XSeepage 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. ystem Elev. 7. Final Grade <br /> Required(sq. ft.) Proposed(sq.ft.) (Gals/day/sq.ft.) (Min./inch) Elevation <br /> 7`-/SQ 6e) & Feet A10� Feet <br /> VII. TANK Capacity <br /> INFORMATION <br /> in gallons Total #of Prefab Site Fiber- Exper <br /> New ExistingGallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App <br /> Tanks Tanks strutted <br /> Septic Tank or Holding Tank .PS �— ❑ ❑ El El Ej <br /> Lift Pump Tank/Siphon Chamber ❑ El ❑ El <br /> VIII. RESPONSIBILITY STATEMENT <br /> I,the undersigned,assume responsibility for installs ' the onsite <br /> _LWage system shown on the attached plans. <br /> Plumber's Name:(Print) Plumb e:( St ps) M / PRSW No.: Business Phone Number: <br /> Vr '715--376 -X76 <br /> Plumber's Address(Street ity,State,Zi Code): <br /> P o e1v r s .3 <br /> IX. COUNTY/ DEPARTMENT USE ONLY <br /> Disapproved Sanitary Permit F OndudesG(oundwater ate Is ue Issum A t Sign r PS) <br /> Surcharge Fee) <br /> *ApprovedrE]Owner Given Initial ,56 <br /> Adverse Determination VV <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SHD-6398(H.05/94) DISTRIRLITION. Original to Cmu�l y,One cu Py To: Safety&Ruildinye Divciun,Owner,Plumber <br />