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Safety and Buildings Division <br /> :"� Bureau of Building Water System, <br /> � ; SANITARY PERMIT APPLICATION 201 E.Washington Ave. <br /> In accord with ILHR 83.05,Wis.Adm.Code P O.Box 7969 <br /> Macho ,WI 53707-7969 <br /> • Attach complete plans(to the county copy only)for the system,on paper not less count <br /> than 8 112 x 11 inches in size. 4101 <br /> State Sanitary Permit Number <br /> • See reverse side for instructions for completing this application 3o <br /> The information you provide may be used by other government agency programs ❑Check it revision to previous application <br /> ]Privacy Law,s. 15.04(1)(m)]. State Plan I.D.Number <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION <br /> Property Owner aj"e Property Location <br /> ON �. ,$'411/4 .S 4J t/a,S b T y0 ,N. R/5^E(or W <br /> PropertDyOwner's Maillnq�ress Lot Number Block Number <br /> TTUU CC��TT^^ �e_ <br /> CityStat 1 Zip Code Phone Number �.$73 Subdivision Name or CSM Number <br /> y Nearest Road / <br /> II: TYPE F BUILDING: (check one) ❑ State Owned o vlage �'/r}G�So� <br /> ❑ Public 1 or 2 FamilyDwelling-No.of bedrooms own OF <br /> III, BUILDING USE: (If building type is public,check all that apply) <br /> Parcel Tax Number(s) <br /> 1 ❑ Apartment/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 1�New 2 ❑ Replacement 3. ❑ Replacement of 4_ ❑ Reconnection of 5. ❑ Repair of an <br /> r'`System System Tank Only Existing System - Existing System <br /> ---------------------Y-------------------g-y---- teIssu - <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 /> 110 Seepage Bed 21 ❑Mound 30❑Specify Type 41 ❑Holding Tank <br /> 22 In-Ground Pressure 42❑Pit Privy <br /> 12[]Seepage Trench ❑ 43 Vault Privy <br /> 13[:]Seepage Pit <br /> 14❑System-In-Fill <br /> VI. ABSORPTION SYSTEM INFORMATION: <br /> 1.Gallons Per Day 2. Absorp.Area 13. Absorp.Area 4. Loading Rate S. Pert. Rate 6. System Elev. Elevation 7, Final rade <br /> Req`uir�red (sq. ft.) Prop sed(sq.ft.) (Gals/day/sq.ft.) (Min./inch) yrs= Feet 77, 7 <br /> X 0 O / �� i Feet <br /> VII. TANK -apR;Gallons <br /> Site Fiber- Exper <br /> INFORMATION in gaal Manufacturer's Name cone eee con- steel glass Plastic App <br /> New strutted <br /> TanksSeptic Tank or Holding Tank rNas�� �El <br /> „ ❑ ❑ <br /> Lift Pump Tank/Siphon Chamber <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 Signature:( O tamps) MP/MPRSW No.: Business Phone Number: <br /> Plumber's Name:(Pnn 9 <br /> GJ af_> 6/,*7 �-��— T <br /> Plumber's Addre�s4Street,city,State,Zip Code): <br /> IX. COUNTY/ DEPARTMENT USE ONLY <br /> tlndt,desGtoundwater ate suedffIssuing gnatu <br /> ❑ pP ( s <br /> Disa roved Sanitary Pit Fee Surcharge fee) <br /> �w <br /> pproved ❑Owner Given Initial <br /> Adverse Determination /V <br /> X. CONDITIONS OF APPROVAL/ REASONS FOR DISAPPROVAL: <br /> SHU-6398(tt.OS/94) <br /> DMRIRUTION: Original to county,One copy To: Safety&Rui ding,Divninn,Owner,Plumber <br />