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J <br /> Safetyand Buildm s ivision <br /> SANITARY PERMIT APPLICATION Bureaof 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 County �� <br /> than 8 1/2 x 11 inches in size. C� <br /> • See reverse side for instructions for completing this application s ate <br /> SSaanit}/a'jr�y r/ryp��)N be <br /> The information you provide may be used by other government agency programs " ` `-' /y(II-,�� <br /> 9 Y P 9 ❑Check if revision to previous application <br /> (Privacy Law,s. 15-04(1)(m)1. <br /> State Plan I.D.N her <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION <br /> Propert Owner Name Property Location <br /> 1/4 1/4,Sg, 41 ,N, R 1$ E(orQ11 <br /> . <br /> Prop rt Owner's Mailing Address Lot ber <br /> U 04. Lo�- Z �2 <br /> City,Sta Zi Code (ho1Zju �r Subdivisp�Nmeo:CSvtNumber <br /> II. TYPE OF BU LDING: (check one) ❑ State Owned E] it� W N est Road <br /> ❑ Public 1 or 2 FamilyDwelling- No. of bedrooms 2- vii age 1C <br /> Town OF y <br /> III. BUILDING USE: (If building type is public,check all that apply) Parcel Tax Number(s) <br /> 1 ❑ Apartment/Condo 032 .SZZZ 07- <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 00 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 /> 1 1Seepage Bed 21 E]Mound 30 E]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 /> Requ red (sq. ft.) Proposed(sq. ft.) (Gals/day/sq.ft.) (Min./inch) Elevation <br /> Z . �� �• Feet _0 Feet <br /> VII. TANK Capacity <br /> INFORMATION in gallons Total #of Manufacturer's Name Prefab. Site Fiber- plastic Exper- <br /> New Existin Gallons Tanks concrete Con- Steel glass App. <br /> Tanksl Tanks strutted <br /> Septic Tank or wo ❑ Q I QElEl <br /> IiftPump Tank/Siphon Chamber El ❑ ElEl ❑ 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's Name: (Print) Plumber's Signatur :(N Stamps) MP/MPRSW No.: Business Phone Number: <br /> l( S — <br /> umber's Address treet,Ci y,State,Zip Code) S66 %7 <br /> 3s OilwregW . si,,03 <br /> IX. COUNTY/ DEPAR11MENT USE ONLY <br /> E]Disapproved Sanitary Permit Fee (Includes Groundwater f6ateissuedssuingAgent Si nat re 0Stamps) <br /> proved [-]Owner Given Initial u harge Fee) <br /> Adverse Determination LlIyA <br /> X. CONDITIONS OF APPROVAL/REASONS FOR PROVAL: <br /> SHE)6398(R.05/94) DISTRIBUTION. Original to CnurJ y,One copy To: Suety 8 RuilJin9s❑im:ion.Owner,Plmnber <br />