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� <br /> Safet"y anBuildinon <br /> SANITARY PERMIT APPLICATION BureauofdBuildingWater System: <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 County ' <br /> than 81/2 x 11 inches in size. <br /> • See reverse side for instructions for completing this application StateSnry Permit Number _ <br /> The information you provide may be used by other government agency programs ❑check it revisions to previous application <br /> [Privacy Law,s. 15.04(1)(m)]. State Plan I.D.Number <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORINIATION ---v b) <br /> Property Owner Nameopert Location <br /> LA e!' n4 S "ClQv4 r 114,S <br /> Property Owner' Miing Ad�jdress Lot Number Block Number <br /> coW • rho. U . <br /> Gty, tate Zip Code P one Nkunber mMr <br /> II. TYPE F B I DING: (check one) ❑ Staf a Owned 0 Cit� Nearest Road <br /> Public 1 or 2 Family Dwelling- No.of bedrooms -� Town of 09 D C0 - RQL( <br /> Ill. BUILDING USE: (If building type is public,checkallthatapply) Parcel TaxNumber(s) J ( / <br /> 1 E] Apartment/Condo 690- 4 3q — 0 / 7�b <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. E] Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an <br /> "System System Tank Only Existing System Existing System <br /> B) E] 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 /> 11IRISeepage Bed 21 ❑Mound 30❑Specify Type 41 ❑Holding Tank <br /> 12"E]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 S. Perc. Rate 6. System Elev. 7. Final Grade <br /> Required(sq.ft.) Proposed(sq. ft.) (Gals/day/sq. ft.) (Min. h q ( Elevation <br /> 4S 6)43 CPSID7 -1 7 •� Feet ` , Feet <br /> Ca act <br /> VII. FORMATION in gallons Total #of Manufacturer's Name Prefab coy Fiber- Plastic Exper <br /> New Existin Gallons Tanks Concrete Steel glass App. <br /> Tanks Tanks f strutted <br /> Septic Tank or Holding Tank �0 000 El El 0 <br /> Lift Pump Tank/Siphon Chamber LEA ❑ 11 ❑ ❑ 0 <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' Signature( tamps) MP/MPRSW No.: Business Phone Numb r: <br /> 1� Z6 S- <br /> PI tier's Address(Street,City,State, Code): <br /> 2-1-4)o w S <br /> IX. COUNTY/ DEPARTMENT USE ONLY <br /> El Disapproved Sanitary Permit Feel 1'ndude,e1onndwat7r 1715SUed Issuing Age gryfurY tamps) <br /> A rOVed �6 O6 --rc ge fee) � `6 <br /> DK <br /> PP ❑Owner Given Initial cr-7�� / <br /> Adverse Determination <br /> X. CONDITIONS OF APPROVAL/ REASONS FOR DISAPPROVAL: <br /> SBD-6398(R.Mal DISTRIBUTION: Original to Calmly.One copy To: safety B Buildings Dim�Ion.Owner,Plumber <br />