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� C' <br /> Safety and Buildings ivision <br /> SANITARY PERMIT APPLICATION Bureau aBuildingWaterSystems <br /> (E! <br /> 201 E.Washington Ave. <br /> !=n P.O.Box 7969 <br /> In accord with[LHR 83.05,Wis.Adm.Code Madison,WI 53707-7969 <br /> • Attach complete plans(to the county copy only)for the system,on paper not less County �(W /� <br /> than 81/2 x 11 inches in size. O <br /> State Sanitary Permit Number <br /> • See reverse side for instructions for completing this application ;j I� <br /> The information you provide may be used by other government agency programs / ❑Che it'Lion cd previous application <br /> [Privacy Law,s. 15-04(1)(m)l. ��, �t State Plan ID-Number <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL IN RMATION <br /> Prope Owner Name VPrppert_tlrc 1 i , 3 <br /> C: j�l/4 �S t/4,S S T Nr R �b E(or W <br /> Property wner's Maili g Address Lot Number <br /> L. <br /> City tate Zi ode (h ne Number D Subdivision N W¢or C M Number <br /> Q. Z FVYt© <br /> II. TYPE OF BUILDING: (check one) ❑ State Ownedit� Ne rest Road <br /> ❑ <br /> Village <br /> 1 El Public 1 or 2 FamilyDwelling- No.of bedrooms 3 Town OF <br /> III. BUILDING USE: (if buildingtypeispublic,checkallthatapply) Parcel TaxNumber(s) <br /> 1 ❑ Apartment/Condo <br /> 2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Owtdoor 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 /> �+New 2y . Replacement 3. E] Replacement of 4. E] Reconnection of 5. E] Repair of an <br /> A) 1. Y" <br /> System ❑ System _____________ Tank Only -------------ExjstingSystem----------ExistingSystem <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)dSeepage 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. System Elev. 7. Final Grade <br /> Re uired (sq.ft.) Pro osed(sq.ft.) (Gals/day/sq.ft.) (Min./inch) Elevation <br /> 4� ,-S <br /> 17, <br /> Feet .3 Feet <br /> Ca ac <br /> VII. TANK in allon5 Total #Of Prefab Site Fiber- Plastic Exper <br /> INFORMATION g Gallons Tanks Manufacturer's Name Concrete Con- steel glass App <br /> New Existin strutted <br /> Tanks Tanks ❑ <br /> Septic Tank or Holding Tank 00 ❑ ❑ ❑ ❑ <br /> Lift Pump Tank/Siphon Chamber <br /> VIII. RESPONSIBILITY STATEMENT <br /> I,the undersigned,assume responsibility for installation of the onsite sewage system shown on the attached plans. <br /> Plumber Si natu e:( Stamps) MP/MPRSW No.: Business Phone Number: <br /> Plumbelr'sName:(Print) g - - <br /> Plumber's Address(Street,City,St te,Zip Code): <br /> Z o - <br /> 35 E R <br /> IX. COUNTY/ DEPAR ME T USE ONLY ' <br /> Disa roved Sanitary Permit FeQ OntludesGroundwater ate ssue Issuing Agent Si atu IN ) <br /> ❑ pp Surcha ge fee) <br /> pproved ❑Owner Given Initial <br /> Adverse Determination t <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(R.05/94) DISTRIBUTION. Original to county.One copy To: Safety 8 Buildings Division,Owner,Plumber <br />