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ON COMPUTER/SCANNED <br />SANITARY PERMIT APPLICATION <br />In accord with ILHR 83.05, Wis. Adm. Code <br />M ctw <br />Safety and Buildings Division <br />Bureau of Building Water System. <br />201 E. Washington Ave. <br />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 <br />Co <br />than 812 x 11 inches in size. <br />&gdur <br />St to Sanitary Number <br />• See reverse side for instructions for completing this application <br />� <br />The information you provide may be used by other government agency programs <br />ElChel:0 revision Iopp333333revious`application <br />(Privacy Law, s. 15.04 (1) (m)]. <br />State Plan I.D. Number <br />I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION <br />Prope Owner <br />Name <br />Property Location <br />S N, R _7E (or W <br />S <br />1/4 1/4, 16.,T, <br />Propert wner's Mailing Address <br />Lot Number <br />3 <br />Block Number <br />o n. <br />C t State <br />In BSf t W I• <br />Zi Code <br />8 3 <br />one Number <br />Its)8c - 3 <br />Subdivision Name or CSM Number <br />II. TYPE OF BUILDING: (check one) ❑ State Owned <br />❑ city <br />Nearest Road <br />IL <br />❑ Public 1 or 2 FamilyDwelling- No. of bedrooms <br />❑ Village / /�� J <br />Town OF WMA <br />,�`� <br />/ W40 <br />!II. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number(s) <br />036 $ 00 0/ . ;00 <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. ❑ New 2.X Replacement 3. ❑ Replacement of 4_ ❑ Reconnection of 5_ ❑ Repair of an <br />System SystemTank 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 Aseepage 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 />Required (sq. ft.) Pro sed (sq. ft.) (Gals/day/sq. t.) (Min./inch) evationSoo <br />Z Feet Feet <br />VII. TANK <br />INFORMATION <br />'Capacity <br />in gallons <br />Total <br />Gallons <br /># ofPrefab. <br />Tanks <br />Manufacturer's Name <br />Concrete <br />Site <br />Con- <br />Steel <br />Fiber- <br />glass <br />Plastic <br />Exper. <br />App. <br />New Existing <br />st <br />nks Tanks <br />Septic Tank or Holding Tank <br />--- <br />14 <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />Lift Pump Tank /Siphon Chamber <br />1 <br />❑ <br />I ❑ <br />1 ❑ <br />❑ <br />I ❑ <br />I ❑ <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) <br />Plumber's Signature: <br />uW <br />MP/MPRSW No.: <br />Business Phone mb <br />7m OR <br />P mber's Address (Ste t, City, St te, Zip Code): j <br />W(. 3 <br />w .35' <br />IX. COUNTY / DEPARTMENT USE ONLY <br />4<pproved <br />❑ Disapproved <br />❑ Owner Given Initial <br />Sanitary Permit Few (Induces Groundwater <br />urcharge Fee) <br />���� <br />Date Issue Issuing A t Si atur (No t ps) <br />6�% Q <br />eM� <br />` <br />Adverse Determination <br />V,41-4 <br />X. CONDITIONS OF APPROVAL / REASONS FORDISAPPROVAL: <br />