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Safety andu"ilclings Division <br /> ^" 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 C ty <br /> than 8 12 x 11 inches in size. <br /> • See reverse side for instructions for completing this application State Sanitary Permit Nu er <br /> 3a s� <br /> The information you provide may be used by other government agency programs ❑Check it revision to previo s application <br /> [Privacy Law,s. 15.04(1)(m)I- State Plan I.D.Number <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION <br /> Pr -erty Owner Name , Proper LOcati <br /> t/4 w , T N, R �5/ E(or) <br /> Prop�rty_O,wner's g Addr s, L Lot Number Block Number p <br /> City,StateLp Code Phone Number Subdivision Name or CSM No er <br /> ( - I �� G <br /> II. TYPE OF BUILD[ : (check one) ❑ State Owned ❑ city Nearest Road <br /> •/�� C] Village <br /> Public 1 or 2 FamilyDwelling- No.of bedrooms —la-,scown OF <br /> III. BUILDIN USE: (If building type is public,check all that apply) Parcel Tax Number(s) <br /> 1 ❑ Apartment/Condo Day -� I ►a-- - g� <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. 1 Replacement 3. ❑ Replacement of 4- ❑ Reconnection of 5. ❑ Repair of an <br /> System ystem Tank Only ----- ----- Existing System --- -- 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>g�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 6. System Elev. 7. Final Grade <br /> 3to Req .ft.) Pro os .ft.) (Gals/day/sq.ft.) (Min./inch) E�lievatio <br /> _ff �`-F, Feet qt 1 Feet <br /> VII. TANK Capacity site <br /> INFORMATION in gallons Galltons Tanks Manufacturer's Name Cone Prefab. <br /> Con- Steel glass Plastic APpr <br /> New Existin strutted <br /> Tanks I Tanks <br /> Septic Tank or Holding Tank C`X^>`D S E1 Q El <br /> Lift Pump Tank/Siphon Chamber 5::r) Q ❑ Ej Ej O <br /> VIII. RESPONSIBILITY STATEMENT <br /> I,the undersigned,assume responsibili for installation of the onsite sewage system shown on the attached plans. <br /> Plumber's Name:(Print) Plu er Sig tur ostamps) M /MP SW No.: Business Phone Number: <br /> d n -k, <br /> Plumber's Address(Street,City,State,Zip �de): <br /> v N . S l v (D <br /> IX. COUNTY/ DEPARTMENT USE ONLY <br /> ❑Disapproved San> ry P rmR Fee (in-.Ode,cro�ndwater ate Issued suing a Signa re N ps) <br /> 75 Surcharye Fee) `{ Ze <br /> Illp proved ❑Owner Given Initial /U{•Q�� � .Y/,( <br /> Adverse Determination <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> 5HD-b398(R.OS/94) DISTRIBUTION: Original to Coonty,One aipy To: safety 8 s,.a&ru},ri m_ion,Owner,Plumber <br />