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Safety and Buildings Division <br /> ^�■ ■•■' SANITARY PERMIT APPLICATION Bureau BuildingWater Systems <br /> ri'�L�7f1 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 12 x 11 inches in size. s^,t.} <br /> ri <br /> • See reverse side for instructions for completing this application State Sanitary Permit Number <br /> cz;? 8 7/ 717 <br /> The information you provide may be used by other government agency programs ❑Check i(revision to previous application <br /> [Privacy Law,s- 15.04(1)(m)l- State Plan I.D.Number Q <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION <br /> Property Owner Name Property Location , <br /> 7^ fl a �✓% -S n�s.J' /4 1/4,5 T Ss ,N, R/ f E(o W <br /> Property Owner's Mailing Address , p of Number Block Number <br /> City,State Zip Code Phone Number Subdivision N CSM Number <br /> 11. TYPE OF BUILDING: (check one) E] State Owned ❑ city Nearest Road <br /> ❑ Village <br /> ❑ Public EXI or 2 Family Dwelling-No.of bedrooms own Or ALJ `ci nu/C-0 9T <br /> 111. BUILDING USE: (if buildingtypelspublic.checkallthatapply) Parcel TaxNumber(s) <br /> aoS-A/aa - 042, foo <br /> 1 F1Apartment/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. �2 New 2, ❑ Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an <br /> System System ----------- ------ Tank-Only- ---- Existing System--- ------Existing System <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 /> 11epage Bed 21 ❑Mound 30[:]Specify Type 41 ❑Holding Tank <br /> 12 n 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 15. Perc. Rate 6. System Elev. 7. Final Grade <br /> Required(sq. ft.) Proposed (sq.ft.) (Gals/day/sq.ft.) (Min./inch) Elevation <br /> o -/- "1 Feet Feet <br /> VII. TANK Capa&Tanks <br /> site <br /> in gaTotal #of Manufacturer's Name Prefab. Con- steel Fiber- Plastic Exper_ <br /> INFORMATION Gallons Tanks Concrete glass App. <br /> New strutted <br /> Tanks <br /> Septic Tank or Holding Tank NC/t� <br /> Lift Pump Tank/Siphon Chamber -/-4 El El ff EI El <br /> VI11. RESPONSIBILITY STATEMENT <br /> I,the undersigned,assume responsibility for installation of the onsite sewage system shown on the attached plans. <br /> Plumber's Name:(For nt) Plumber's Signature:(No Stamps) MP/MPRSW No.: Business Phone Number: <br /> C� q,/e w� o :r, eo,; /ref iC r�� 17, �� � `l'i <br /> Plumber's Address(Street,City,State,Zip Crpde). <br /> IX. COUNTY/ DEPARTMENT USE ONLY <br /> anitary e Fee (Induder )water ate l ue Issuing Aye Sign o tamps) <br /> El Disapproved S <br /> ��Surchargefee) <br /> eeFee) <br /> .�,pproved ❑Owner Given Initial <br /> Adverse Determination <br /> X. CONDITIONS OF APPROVAL/REASONS FO APPROVAL: <br /> SRD-6398(R.W94) DISTRIBUTION'. Original to rnur,ty,One copy TO: Safety 8 Buildings DivuiOn,Owner,Pi.tnWr <br />