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n>r1_ <br /> 141111, Safety and Buildings Division <br /> i+lC..�r'.R SANITARY PERMIT APPLICATION Bureau Building Water Systems <br /> 201 E.Washington Ave <br /> Inaccord 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 8 112 x 11 inches in size. TjG, <br /> • See reverse side for instructions for completing this application StateSan itj(y PerrPit Number <br /> 00 <br /> The information you provide may be used by other government agency programs L]Check If revision to previous application <br /> [Privacy Law,s. 15.04(1)(m)]. State Plan I.D.Number AIA- <br /> Property <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION <br /> Owner Name 1� O P operty Location ,/ <br /> C VaIV� EV�t s (yt/1/4 N 1/4,S T 7O ,N, R 14 E(or W <br /> Property Owner's Mailing Address Lot Number Block Number <br /> 101 <br /> Gt ,StatZip Code Phone Number Subdivision ame or CSM Number <br /> ul 5 Ll 30 ( > L U Les Woods <br /> II. TYPE O BUILDING: (check one) ❑ State Owned ❑ city ,j Nearest,Road J <br /> ❑ Village 5U 1 + <br /> ❑ Public Ig 1 or 2 Family Dwelling-No.of bedrooms CP— Town OF <br /> III. BUILDING USE: (If building type is public,check all that apply) Parcel TaxNumber(s) <br /> 1 ❑ Apartment/Condo 0t "117SOD-300 <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 IineA. Check box on line B, if applicable) <br /> A) 1. New 2. [:] Replacement 3. [:] Replacement of 4_ E] Reconnection of 5. E] Repair of an <br /> - System <br /> 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 /> 1 1 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 /> O Re u'red (sq.ft.) Proposed(sq.ft.) (Gals/day/sq.ft.) (Min./ins b Eleevation <br /> 3 © , 6 1 Z •Z Feet ^ Zr Feet <br /> Capacity <br /> VII. FORMATION in gallons Total #of Manufacturer's Name Prefab Si Fiber- Plastic Exper <br /> Gallons Tanks concrete steel glass App. <br /> New Existin strutted <br /> Tanks I Tanks <br /> Septic Tank])r Holding Tank SQ I I e lK ❑ EJ ❑ ❑ El <br /> Lift Pump Tank/Siphon Chamber ❑ ❑ ❑ ❑ ❑ ❑ <br /> VIII. RESPONSIBILITY STATEMENT <br /> I,the undersigned,assume responsibility for installation of the onsite sewage system shown on the attached plans. <br /> PI u tier's Name:( rin PI mber'sSignatu e: oStamps) L)LDS7, <br /> P/MPRSW No.: Business Phone Number: <br /> P (S �e ,t (06— <br /> Plumber's Addr{ss(Street=City,Stat ,Zip Cod :� �nr — W; <br /> J /WA V+n. Jy,Q <br /> IX. COUNTY/ DEPARTMENT USE ONLY <br /> ❑Disapproved Sanitary Permit Fee (IncludesGrouedwaler ate Issue Issuing Age t Si iture ) <br /> roved �5 rcharge Fee) <br /> pp ❑Owner Given Initial' _ 17 <br /> Adverse Determination �C-- <br /> X. CONDITIONS OF APPROVAL/ REASONS FOR DISAPPROVAL: <br /> SHO6398(R.05/94) DISIRIBUTION'. Original to Counly,One copy To: 5arety 8 Buildings Div,s ion,Owner,Plumber <br />