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t� ,r"tee Safety and Buildings ;vision <br /> r�i`r�g'• SANITARY PERMIT APPLICATION Bureau of Building Water Systems <br /> 201 E.Washington Ave. <br /> In accord with ILHR 83.05,Wis.Adm Code P .Box 7969 <br /> Ma ison,WI 53707-7969 <br /> • Attah complete plans(to the county copy only)for the system,on paper not less County <br /> than 81/2 x 11 inches in size. <br /> • See reverse side for instructions for completing this application State Sanitar Per Num r <br /> The information you provide may be used by other government agency programs <br /> (Privacy law,s. 15.04(1)(m)]. ❑Check if revision to previous application <br /> State Plan I.D.Number <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION <br /> Property Owner Name Property Location <br /> eua�eyn� e1/4 SE'1/4,5T3� ,N, R`�j <br /> Property ner's M iling_Address I Lot Number Block Number <br /> City,sitate Zip CcIde Phone Number Subdivision Name or CSM Number <br /> r Gcer S ¢1 ( 1 r <br /> II. TYPE OF BUILDING: (check one) ❑ State Owned -7 OC ity Nearest Road <br /> Public 1 or 2 Family Dwelling- No.of bedrooms 3 village r7 d- <br /> ill. <br /> of gy1 '�1 _fflO /ittis to <br /> III. BUILDING USE: (If building type is public,check all that apply) Parcel E] TaxN� Jummber(s)�7 a <br /> 1 Apartment/Condo 0 0t ^ C) oo <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. p Replacement 3_ [j Replacementof 4. E] Reconnection of 5. ❑ Repair of an <br /> ______System __ ___System Tank Only ExistingSy _ ____Existing- -- <br /> System syste- <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 p9 Seepage 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.Area 3- Absorp.Area 4. Loading Rate 5. Perc. Rate 16. System Elev. 7. Final Grade <br /> Req ired(sq. ft.) Proposed(sq.ft.) (Gals/day/sq. ft.) (Min.l� Elev tion <br /> �l e ?Xi 7 Feet Z Feet <br /> VII. TANK Capacity <br /> INFORMATION in gallons Total #of Manufacturer's Name Prefab- Site Fiber- plastic Exper <br /> New ExistingGallons Tanks Concrete Con- Steel glass App <br /> Tanks Tanks <br /> strutted <br /> eptic Dnk or Holding Tank ,(}(Jb t e 0 El1:1E] <br /> Lift Pump Tank/Siphon Chamber <br /> VIII. RESPONSIBILITY STATEMENT El EITEI El Q <br /> I,the undersigned,assume responsi 'lity for installation of the onsite sewage system shown on the attached plans. <br /> Plu ber' Name:( rin PI tuber' Signat re' o Stamps) MP/MPRSW No.: Business Phone Number: <br /> ��S kq Xz;76— cJ <br /> P is ddress(Stye t,City,State Zip Code <br /> / S— L.-� =-t_ RC1 SJ e(� W i S it <br /> IX. COUNTY/ DEPARTMENT USE ONLY <br /> ❑Disapproved Sanitary Permita llncludesGroundwaler ate IssuedIssuing Ag t Signatu ( Stamps) <br /> roved ❑ Surcharge Fee) ` <br /> PP Owner Given Initial 7 <br /> Adverse Determination <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> 5BD-6398(R.05/94) DISTRIBUTION: Original to County,One copy To: Safely&Buildings Division,Owner,Plumber <br />