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Safety and Buildings Division <br /> SANITARY PERMIT APPLICATION Bureau 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 /> i Attach complete plans(to the county copy only)for the system,on paper not less County d -7 5c;2-- <br /> than 8 112 x 11 inches in size. ei l` e— <br /> • See reverse side for instructions for completing this application State Sanitary Permit Numbr <br /> .3X66 <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)]. State Plan I.D.Number <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION N <br /> Property Owner Name Property Location <br /> 1/4 1/4,S / T Y6 ,N, R 1� E(orKZO <br /> Property Owner's Mailing Address Lot Number "—r i Biock-PFdcaher <br /> 35 S' /7 s7: 44- 7c'sm✓, I(aP.B' <br /> City,State Zip Code Phone Number Subdivir ^'- "SMNurnr-- <br /> CA•i� ` /e- i'V/u 5,5-0 (dia 9 - V©hner LK Swlo. <br /> II. TYPE OF BUILDING: (check one) ❑ State Owned ❑tilt- so/t� Nearest <br /> ❑ Public 1 or 2 FamilyDwelling-No. of bedrooms r_1 <br /> Vil age ,pp <br /> own OF NaN21 en <br /> III. BUILDING USE: (If building type is public,check all that apply) Parcel TaxNumber(s) 9 (lstldi"'Li](/., <br /> 1 [:] Apartment/Condo P,4-4, �� " �,� Oa `—4�60 <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. ❑ Replacement 3_ ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an <br /> System 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 /> Required(sq- ft.) Proposed(sq.ft.) (Gals/day/sq.ft.) (Min./inch) Elevation <br /> Feet Feet <br /> Ca acit <br /> VII. N ORMATION <br /> ..Ca, <br /> n gallons Total #Of Prefab. Site Fiber- Plastic Exper <br /> Gallons Tanks Manufacturer's Name concrete Con Steel glass App. <br /> New Existingstrutted <br /> Tanks Tanks / <br /> Septic Tank or Holding Tank 7.SP" .5-6 / /� i^Q cr da ❑ ❑ ❑ ❑ ® ❑ <br /> Lift Pump Tank/Siphon Chamber A ❑ ❑ ❑ 1 ❑ ❑ ❑ <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:( oStamps) MP/MPRSWNo.: Business Phone Number: <br /> Plumber's Address(Street,City,State,Zip Code): <br /> L3 o X S"—� i/s �✓ 2- <br /> IX. <br /> IX. COUNTY/ DEPARTMENT USE ONLY <br /> E]Disapproved Sanitary Permit Fee (includes Groundwater ate ssue Issuing Agent na <br /> Approved ❑Owner Given Initial /So a"o Surcharge fee) <br /> Adverse Determination <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SHE)6398(n.01194) DKIBIBUTIONoriginal to Cnunly,One copy To: Safety&Buildings Diveion,Owner,PlumWr <br />