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SANITARY PERMIT APPLICATION r� fetyandBudinggsater Division <br /> � Bureau of Building Water S <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 Coun <br /> than 8 1/2 x 11 inches in size. <br /> • See reverse side for instructions for completing this application State Sanitary Permit Number <br /> 3 I_q 6a8 <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)). <br /> State Plan I.D.Number <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION <br /> Prop rty Owner Name / Property Location <br /> (* k e (�! e 1/4 1/4,53T Ya ,N, R/S--E(or W <br /> Property Owner's Mailing Address Lot Number B}gElr.p�yrs�er <br /> S .? oJfi ve, <br /> Cit _'e c Zip Code Phone Number Warne or CSM Number <br /> /' Rfcr/c ! J 3Y.832 ( 953_!%P96 V a <br /> II. TYPE OF BUILDING: (check one) ❑ State Owned 0 City Nearest Road <br /> ❑ Village �— <br /> Public 1 or 2 Family welling- No.of bedrooms a g.Town OFV 011_) /r,¢ <br /> III. BUILDING USE: (If building type is public,check all that apply) Parcel TaxNumber(�s)) <br /> 1 E] Apartment/Condo ©x' l CFOC) <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. DNew 2. [:] Replacement 3. E] Replacement of q E] Reconnection of 5. E] Repair of an <br /> ---- <br /> ystem System - - ---- Tank Only ---- Existing System Existing System <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$,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 /> goo <br /> Required (sq. ft.) PP (sq.ft.) (Gals��sq.ft.) (Min./inch) ?/ Feet Elevation <br /> O� 1 Ga � Feet <br /> VII. TANK Capacity <br /> INFORMATION in gallons Total #of Manufacturer's Name Prefab. Site Fiber- Exper <br /> New Existin Gallons Tanks Concrete Con- Steel glass Plastic App <br /> strutted <br /> Tanks Tanks <br /> Septic Tank or Holding Tank $Od add s El 0 ❑ El ❑ <br /> Lift Pump Tank/Siphon Chamber ❑ EJ ❑ 0 1 E1 ❑ <br /> VI11. RESPONSIBILITY STATEMENT <br /> I,the undersigned,assume responsibility for installation of the onsite sewage system shown on the attached plans. <br /> Plumber's Name:(Prin Plumber's Signature No Stamp MP/MPRSW No.: Business Phone Number: <br /> Plumber' Address(Street,City,State,Zip Codv: <br /> IX. COUNTY/ DEPARTMENT USE ONLY <br /> ❑Disapproved Sanitar Per it Fee (includes Groundwater ate issue Issuing Agent Signature o amps) <br /> roved Surcharge fee) <br /> pp ❑Owner Given Initial <br /> Adverse Determination <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SKI)-6398(R GSN4) DISTRIBUTION: Original to(musty,One copy To: Safety a RuilJings Dim;Ion,owner.%urnuer <br />