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SANITARY PERMIT <br /> omrSafety and Buildings Division <br /> RMIT APPLICATION _ <br /> �r�LAA Bureau of Building Water Systems <br /> ` In accord with ILHR 83.05,Wis.Adm.Code 201 E.Washington Ave. <br /> P.O.Box 7969 <br /> • Attach complete plans(to the count co Madison,WI 53707-7969 <br /> y Copy only)for the system,on paper not less county �/& 33 <br /> than 8 t/z x 11 inches in size. <br /> • See reverse side for instructions for completing this application uit �, <br /> State SanitaryperrP�Nur9ber� <br /> The information you provide may be used by other government agency programs JJ�� <br /> I Privacy Law,s. 15.04(1)(m)). ❑Check it revision to previous application <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION <br /> State Plan I.D.Number04 <br /> Property Owner Name t c 111 /3`/ 03� <br /> Property Location <br /> Id / ti iJ E/a sN t/a,S f T N, R��E(or <br /> Property Ow is Mallin dress Lot Number <br /> 11 <br /> p 5"'p Z i ` / t IA/ D /� Gov <br /> "L � Block Number <br /> 0!2City,State y Zip C ePhone Number Subdivision Name or CSM Uumber <br /> II. TYPE OF BUILDING: (check one) ❑ State Owned ❑ LIt Nearest Road <br /> Public 1 or 2 FamilyDwelling-No. of bedrooms ❑ Village , / �)1 r <br /> DmLJown OF �/ L ✓)/r <br /> III. BUILDING USE: (If building type is public,check all that apply) Parcel Tax Number(s) <br /> 1 ❑ Apartment/Condo V3q/!s7//'"- <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. 1 2. ❑ Replacement 3. Re lacementof <br /> T� stem ❑ P 4. ❑ Reconnection of 5- ❑ Repair of an <br /> ------_Y_ System Tank Only ----- Existing System Existing System <br /> --------------------------------- <br /> ------- ------------- <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 [-] pge Bed 21 El Mound 30 E]Specify Type 41 E]Holding Tank <br /> 12 <br /> E]Seepage Trench 22 Kin-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 /> Require (sq. ft.) Proposed(sq.ft.) (Gals/da /s ft. <br /> � y q. ) (Min./inch) q'`7 Elevation <br /> Z / /�� Feet Feet <br /> VII. TANK ina achy Total #of <br /> INFORMATION g Gallons Tanks Manufacturer's Name Prefab Con Fiber- Plastic Exper <br /> New Existin Concrete strutted Steel glass App. <br /> Tanks Tanks <br /> Septic Tank or Holding Tank /000 00 <br /> Lift Pump Tank/Siphon Chamber a 8 [) - El El <br /> El El ❑ <br /> VIII. RESPONSIBILITY STATEMENT <br /> 1,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 Stamps) MP/MPRSWNo.: Business Phone Number: <br /> []P�t!��mbe�rdress(Street,City,5rtate,Zip Code): <br /> IX. COUNTY/ DEPARTMENT USE ONLY <br /> ❑Disapproved Sanitary Permit Fee 11"1ades Groundwater ate Issue Issuing*99 t Signa ure(N t s <br /> pproved ❑Owner Given Initial S chargefee) <br /> Adverse Determination ,CSS ,2 0 <br /> X. CONDITIONS OF APPROVAL/REASONS FOR 1SAPPROVAL: <br /> S1,10-6398(B.05/94) DISTBIaUTION Original t"eount y,One a/Py To: Safety 8 Building&Divi--ion,Owner,Plumber <br />