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Safet�d Builvision <br /> SANITARY PERMIT APPLICATION Bureau of Building Water System: <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 r _ L <br /> than 8 112 x 11 inches in size. �i! n r. <br /> • See reverse side for instructions for completing this application State Sanitary Permit N�[}/�mber <br /> The information you provide may be used by other government agency programs MIl <br /> ��� nI/ <br /> ❑Check i1 revision to prevrevI 6,ylication <br /> [Privacy Law,s. 15.04(1)(m)]. State Plan I.D.Number <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION <br /> Property Owner Name Property Location _411;L�- <br /> �� � I Z S�1/4,e 1/4,S T3q IN, R�6 E(or <br /> Propert .,r..Owner's Mailing Address , / Lot Number Block Number <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> 4� /ru0,v.f l'�1!U S 7i 7 (5'�7)5`s7-30 7 — <br /> II. TYPE F BUILDING: (check one) ❑ State Owned ILI City Nearest Road <br /> ❑ Village <br /> Public 1 or 2 Family Dwelling- No.of bedrooms 2 MTown0F/_))C e w o i�_j .yl� -//et �' 2 <br /> III. BUILDING USE: (If building type is public,check all that apply) Parcel TaxNumber(s) <br /> /ig - 33ap) -o3 g?1400 <br /> 1 ❑ Apartment/Condo <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. gj New 2- ❑ Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an <br /> ___System --------System __ _______ TankOnly ___________ 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 5. Perc. Rate 6. System Elev. 7. Final Grade <br /> Required(sq.ft.) Proposed(sq.ft.) (Gals/day/sq. ft.) (Min./inch) / Elevation <br /> G r [ G —� �b, Feet y�' Feet <br /> VII. TANK Capacity Site <br /> in gallons Total #of Manufacturer's Name Prefab Con_ Steel Fiber- Plastic Exper <br /> INFORMATION Gallons Tanks Concrete glass App <br /> New Existin strutted <br /> Tanks Tanks <br /> Septic Tank or Holding Tank ;57.0 / �r �c✓ El E1 ❑ <br /> Lift Pump Tank/Siphon Chamber E ❑ ❑ E <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 Signature:(No Sti MP/MPRSWNo.: Business Ph one Number: <br /> Plumber's Address(Street,City,State,Zip Code): <br /> IX. COUNTY/ DEPARTMENT USE ONLY <br /> ❑Disapproved Sanitary Permit Fee (IndudesGroundwater at7,,uX <br /> Issuing A n Ignatur (No S m <br /> A roved wrcharge ee) <br /> pp ❑Odverso etprmi al > � 7 <br /> Adverse Determination / <br /> X. ONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(R 05M) DISTRIBUTION: Original to County,One copy To: Safety 8 Buildings Division,Owner,Plumber <br />