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Safety and Buildings Division <br /> SANITARY PERMIT APPLICATION Bureau of Building Water Systems <br /> 201 E.Washington Ave. <br /> In accord with]LHR 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 Count <br /> than 8 112 x 11 inches in size. <br /> • See reverse side for instructions for completing this application State/S1anitar P rnrc N„mber�SS / <br /> The information you provide may be used by other government agency programs ❑C 'k�II rlev' <br /> so previous application <br /> ]Privacy Law,s. 15.04(1)(m)j. <br /> State Plan LD_Number <br /> 1. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION <br /> Property Owner Name Property Location <br /> e Jr' SOl9l Sa` 1/4 IV,) 1/4,S T YO ,N, R E (or) <br /> Property Owner's Mailing AddIfesy Lot Number flock Number <br /> Cit ,state Zip Code Phone Num r Subdivision Name or CSM Number <br /> 11. TYPE OF BUILDING: (check one) ❑ State Owned ❑ cit❑ Villy NearestR ad <br /> '7 age / <br /> Public EA 1 or 2 Family Dwelling- No. of bedrooms Town of O/} rf1C- <br /> Hl. BUILDING USE: (If building type is public,check all that apply) Parcel TaxNumber(s) rn� <br /> 1 ❑ Apartment/Condo 0 <br /> 2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility <br /> 3 ❑ Campground 7 ❑ Merchandise: Sales/Repairs 11 ❑ Restau ant/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_ d New 2. N Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5 ❑ Repair of an <br /> System System Tank Only Existing Syst(m 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 /> 11 (9Seepage Bed 21 ❑Mound 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. Area3. Absorp.Area 4. Loading Rate 5. Perc. Rate 6. System Elev. 17. Final Grade <br /> O O Required (sq. ft.) Proposed(sq. ft.) (Gals/day/sq. ft.) (Min./inch) Elevation <br /> � ,;Z ,2,/ Feet 1,!51 q, el Feet <br /> Capacity VII. TANK in Cagallons Total #of Prefab Ste Fiber- Exper <br /> INFORMATION Gallons Tanks Manufacturer's Name Concrete C n- Steel glass Plastic App <br /> New Existingstru ted <br /> Tanks Tanks <br /> Septic Tank or Holding Tank ,Q(' 1,0e),9 [I ❑ ❑ ❑ <br /> t ift Pump Tank/Siphon Chamber 40 ❑ ❑ ❑ ❑ <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 Signature:(Nosta s) MP/MPRSW No: Business Phone Number: <br /> G✓A>� /c ho/m "v /l 1I <br /> Plumber'sRdd rens(Street,City,State,Zip Code): , <br /> / Z30S—/ -/ -- <br /> IX. COUNTY/ DEPARTMENT USE ONLY <br /> E]Disapproved Sanitary Permit Fee pndude,Grovndwerer Date Issued Issuin ent Sig nature(No Stamps) <br /> roved Jk C�� surcharge reel <br /> pp ❑Owner G titer itial --Fy/ M J� CU <br /> Adverse Determination w l,'�.� <br /> X. C NDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SHO-6398(R.05194) DMTRIHOToN_ Original to Cnunq.One copy To: Suie,y&Huildlnye Olvuion,Dwneq Plumbx <br />