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An C <br /> Safety and Buildings Division <br /> SANITARY PERMIT APPLICATION g Water System. <br /> /�'IlLf1R Bureau of Building <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 Cowityr_ p <br /> than 81/2 x 11 inches in size. Tsee <br /> • See reverse side for instructions for completing this application State Sanitary Permitumber, <br /> The information you provide may be used by other government agency programs ❑Check it revision to previous applica(ion <br /> [Privacy Law,s. 15.04(1)(m)J. <br /> State Plan I.D.Number O <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION <br /> PropertOwner Na e - Property Location <br /> Wl/4SJ5 1/4,SIG T ,N, Rj :,(oro <br /> Prope `wrier.s M ling Address ' Lot Number Block Number <br /> �� — <br /> Cit ,Stat r. Zip C de Phone Number Subdivision Name or CSM Number <br /> V 5 6 ('71 > -2Zl ,_� <br /> II. TYPE OF UILDING: (check one) ❑ State Owned El City N ares Road <br /> ❑ village p <br /> ❑ Public 1 or 2 Family Dwelling- No.of bedrooms � Town OF <br /> III. BUILDING USE: (if building type is public,check all that apply) Parcel Tax Number(s) <br /> 1 ❑ Apartment/Condo c;L- 3S'!(c -03 -2,OU <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 S_ ❑ Repair of an <br /> ------System - System -- - Tank Only---------------Existingy <br /> System ExistingSystem <br /> stem <br /> ---- - -------------------- ---- <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 S. Perc. Rate 6. System Elev. 7. Final Grade <br /> 3 o o Required (sq. ft) Prop sed(sq.ft.) (Gals/day/sq. ft.) (Min./inch) pQ Elevation <br /> Z 3 Z� LQ. Feet100,25eet <br /> VII. TANK Capacity <br /> INFORMATION in gallons Total #of Manufacturer's Name Prefab Site Fiber- plastic Exper <br /> New Existin Gallons Tanks Concrete Con- Steel glass App. <br /> Tanks Tanks <br /> strutted <br /> ti or Holding Tank `6d�J ¢' -NAr_1El 1:1 El <br /> t Pum nk/Siphon Chamber ,SAO ❑ El ❑ D <br /> VIII. RESPONSIBILITY STATEMENT , <br /> I,the undersigned,assume responsi ility for installation of the onsite sewage system shown on the attached plans. <br /> kX <br /> Plumber'sName:( 1`1 ) PI mber'sSigna ur .(NoStampz) MP/MPRSWNo.: Business Phone Number:ja7 <br /> efS y3Saa 8��- �8" <br /> Plumber's Ad`dlres�(Street,rCi y State,Zip ): <br /> T J l., <br /> IX. COUNTY/ DEPARTMENT USE ONLY <br /> �^ ❑Disapproved Sanitary Permit Fee lend ude,s Groundwater ate IssuedIssuing Agen gnatur (N s) <br /> roved Surcharge ree) <br /> v P El Given Initial C `6 2 <br /> Adverse Determination J J <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SRI)6398(H.W94) 0MRIBUTION. original in Gmmty,One cr py To. Safety 8 Ruildings On, on,Owner,PlumtKr <br />