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D)l cmYLP, <br /> Safety and Buildings Division <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 l�a <br /> than 8 112 x 11 inches in size. N c�C <br /> • See reverse side for instructions for completing this application State Sanitary Permit Kumber <br /> YLJ <br /> 311 a�(o <br /> The information you provide may be used by other government agency programs E]Check It revision to previous application <br /> tPrivacy Law,s- 15.04(1)(m)I. State Plan I.D.Number Di <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION <br /> Property Ow er Name Property Location <br /> e, 1/4 1/4,S,,2 T39 ,N, R/5E(or <br /> Property Ow er's Mailing Address�� Lot Number Blo Number <br /> J ST <br /> City,State Zip Code Phone Number Subdivision Name or C umber <br /> S' ^e.J �✓ 8 c / <br /> II. TYPE OF BUILDING: (check one) ❑ State Owned ❑ city I it Aw Nearest Road <br /> � <br /> E] Public 1 or 2 FamilyDwellingE] Village-No.of bedrooms Town of �Le e e /L�/Rm <br /> III. BUILDING USE: (If building type is public,check all that apply) Parcel TaxNumber(s) <br /> 1 ❑ Apartment/Condo ®� — op/ — O 3— /vim e <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. Replacement 3. E] Replacement of 4- ❑ Reconnection of 5. E] 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 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 S. Perc. Rate 6. System Elev. 7. Final Grade <br /> Required (sq. ft.) Proposed (sq.ft.) (Gals/da /sq.ft.) (Min./inch) Cy/ Elevation <br /> X-3 Q ! � G /A'- Feet F,Ji 9 Feet <br /> Capacity VII. FORMATION in gallons Total #of Prefab. site Fiber- plastic Exper <br /> Gallons Tanks Manufacturer's Name Concrete con- steel glass App. <br /> New Existingstrutted <br /> Tanks Tanks <br /> Septic Tank or Holding Tank 4PA90 ❑ ❑ El <br /> Lift Pump Tank/Siphon Chamberd do 421E] EJ 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'sName:(Pri t) Plumber's Signature:(NoStamps MP/MPRSWNo.: Business Phone Number: <br /> GAJ we_ev <br /> Plumber's Address(Street,City,State,Zip i ode): <br /> -5- <br /> IX. ,COUNTY/ DEPARTMENT USE ONLY <br /> ❑Disapproved Sanitary Permit Fee OndudesGroundwaler ate slue Issuin gent Signature(No Stamps) <br /> ❑Owner Given Initial <br /> A roved surcharge Fee) <br /> pp I y'� <br /> Adverse Determination <br /> ONDITIONS OF APPROVAL/ REASONS FOR DISAPPROVAL: <br /> SBD-6398(8.OS/94) DISTRIBUTIONi original to Caur�ly,0,,e copy To: Safety&Buildings Division,owneq Pl.mWr <br />