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(A) <br /> on Q t <br /> Safety and Buildings D vision <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 County ) /� <br /> than 8 112 x 11 inches in size. , / v <br /> • See reverse side for instructions for completing this application State Sanitary Permit Number <br /> 02(07/07 S� <br /> The information you provide may be used by other government agency programs ❑Check if revision to previous application <br /> [Privacy Law,s. 15.04(1)(m)]. State Plan I.D.�Wmber <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION 1 _526 <br /> Q <br /> Pro erty Oner Name Property Location PC/ <br /> 6e 4�� k� N�-1/4N� 1/4,S�� T3< ,N, RI � E(or) <br /> Property Owner's M ing Address Lot Number Block Number <br /> --- <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> II. TYPE F ILDING: (check one) ❑ State Owned ❑ ityage <br /> / // Nearest Road ,{n— / <br /> Public 1 or 2 Famil Dwellin -No.of bedrooms Town of GW <br /> III. BUILDING USE: (If building type is public,check all that apply) Parcel TaxNumber(s) / <br /> 1 E] Apartment/Condo ,- , ?— qd — 3 6 ZZ— O ( 5-00 <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. 0 New 2. ❑ 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 21 ❑Mound 30❑Specify Type 41AHolding 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 /> ell Feet Feet <br /> Ca act <br /> VII. TANK in allons Total #of Prefab. Site Fiber- Exper <br /> INFORMATION g Gallons Tanks Manufacturers Name Concrete Con- Steel glass Plastic App <br /> New Existin strutted <br /> Tanks Tanks <br /> Septic Tank or Holding Tank VOJO 6tiv � = 1�s ❑ ❑ ❑ 1 ❑ ❑ <br /> Lift Pump Tank/Siphon Chamber ❑ ❑ ❑ ❑ 1 ❑ ❑ <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 N me:(Print) Plumber's Signature:(No Stamps) MP/MPRSW No.: Business Phone Number: <br /> Pur is Address(Street,City,StateZipCode): �y <br /> �_z <br /> IX. COUNTY/ DEPARTMENT USE ONLY <br /> E]Disapproved S itaryPermitFe (Includes Groundwater ate 55Ue Issuing Age tSign lure amps) <br /> roved Surcharge Fee) / <br /> pp ❑Owner Given Initial i� �f �a <br /> Adverse Determination CJ <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SRD-6398(R.05/94) DISTRIBUTION: Original to County.One copy To: Safety&Buildings Division,Owner,Plumber <br />