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()It <br /> -: 1T <br /> Safetyand Buildings Division <br /> �PliiAr. SANITARY PERMIT APPLICATION Bureau of 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 8112 x 11 inches in size. v n_ff L l/� <br /> Nq <br /> • See reverse side for instructions for completing this application State Sanitary Permit Npmbp <br /> The information you provide may be used by other government agency programs ❑Check;e�d`-r-'evision/7o pyere�ou/js(appBcation <br /> [Privacy Law,s. 15 04(1)(m)I. <br /> State Plan I.D. umber <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INF RMATION <br /> Property Owner Name Property Location <br /> /"AA1S "<7 S,Ll1/4 ,,j1/4,S T ,N, RIfE(or)11 ', <br /> Property Owner's Mailing Address n Lot Number Block Number <br /> Utty,StateZip Code <br /> Phone Nu(mmber� / Subdivision Name or CSM Number <br /> lTr��)L c) V1O Cl ( ) ig <br /> II. T PE F B LDING: (check one) ❑ State Owned ❑ t� Nearest//Road p / <br /> Public 1 or 2 FamilyDwelling- No. of bedrooms �— ❑ Town of r` e C crier [U <br /> — <br /> Ill. BUILDING USE: (If building type is public,check all that apply) Parcel Tax Number(s) <br /> lft <br /> 1 ❑ Apartment/Condo "� 03 y— 15,;Lq Son <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 ❑ ServiceStation/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. RNew 2 ❑ Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an <br /> ------System - System - Tank Only Existing System ExistingSystem <br /> stem <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 [:]Seepage Bed 21 25Mound 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 wired (sq. ft.) Proposed(sq.ft.) (Gals/day/sq. ft.) (Min./inch) / Elevation <br /> Feet C? Feet <br /> VII. TANK Capacity <br /> INFORMATION in gallons Total #of MPrefab Site Fiber- Exper <br /> New Existin Manufacturer's Name <br /> Gallons Tanks Concrete Con- Steel glass Plastic App <br /> Tanks Tanks Strutted <br /> Septic Tank o an /OOV /L70U �77 ❑ El ❑ 1:1v ❑ ElElEl El <br /> Pump Tank�•^�-^^����^�^r - 0(% LICA <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:(Pr t) Plumber's Signature:(No Stamps) MP/MPRSW No.: Business Phone Number: <br /> XL <br /> Plumber's Address(Street,City,State,Zip Code): <br /> IX. COUNTY/ DEPARTMENT USE ONLY <br /> ❑Disapproved Sanitary Permit Fee ('dudes Groundwater Date Issuin nt Si at o Stamps) <br /> A roved harge Fee) i <br /> pP ❑Owner Given Initial U SJV <br /> Adverse Determination <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> S8D 6398(R.05N4) DISTRIBUTION: Original to Caunly.One tnpy Ta: Safety 6 Rui61iosn Diw.....Owner,Plumber <br />