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^•• ■•^ Safety and Buildings Division <br /> SANITARY PERMIT APPLICATION Bureau of 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 /> • Attach complete plans(to the county copy only)for the system,on paper not less County a <br /> than 8112 x 11 inches in size. /.3 44 N e <br /> • See reverse side for instructions forcompleting thisapplication StateSanitaryPermit mher�. fL /9�Z6 <br /> as�a <br /> The information you provide may be used by other government agency programs ❑Check if re cion I previous application <br /> [Privacy Law,s. 15.04(1)(m)l. <br /> State Plan I. .Number <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION <br /> Property Owner Name Property Location <br /> ,0/9L0e-- /0/U 1/4 1/4,5_3_j_ T ,�2 ,N, R/S E(or -) <br /> Property Owner's Mailing Address Lot Number6o eJ b lock Number <br /> 6/7n S- /f k 4/ G — <br /> City,State , Z,p Code Phone Number Subdivision Name or CSM Number <br /> Tre.Jr/ Wim` SYs'-3 7 ( 7s— 132-)- <br /> 11. TYPE OF BUILDING: (check one) ❑ State OwnedIt� Nearest Roadr <br /> Ej Public 1 or 2 FamilyDwelling- No.of bedrooms E] Town of J H� F7o/v Cot- <br /> HL BUILDING USE: (If bulldingtype lspubhc,check allthatapply) Parcel Tax Number(s) S <br /> 1 ❑ Apartment/Condo of — �� 3� _o17 200 <br /> 2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Outdo r Recreational Facility <br /> 3 ❑ Campground 7 ❑ Merchandise: Sales/Repairs 11 ❑ Resta ant/Bar/Dining <br /> 4 ❑ Church/School 8 ❑ Mobile Home Park 12 ❑ Servic 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. UNew 2_ [-] Replacement 3- ❑ Replacement of 4. E] Reconnectio of 5. E] Repair of an <br /> _ ___System System Tank Only ExistingSystm Existing System <br /> B) F] ASanitary Permit was previously issued. Permit Number I Date Issued <br /> V. TYPE OF SYSTEM: (Check only one) <br /> Non Pressurized Distribution Pressurized Distribution Experimental Other <br /> 11 C3Seepage 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 Per2- Absorp.Area 3. Absorp.Area 4. Loading Rate 5. Perc. Rate 6V�,�0 <br /> stem Elev. 7. Final Grade <br /> Required (sq. ft.) Proposed (sq. ft.) (Gals/day/sq. ft.) (Min/inch) Ele io <br /> 3 C5 v Day V112 ) Z/,3 :? . e"9 Feet • Feet <br /> TANK Ca act <br /> VII. INFORMATION in gallons 131011tons Ta ks Manufacturer's Name Concrete C n- Steel Fiber- Plastic Exper <br /> New Existin str ted glass App. <br /> Tanks Tanks <br /> Septic Tank or Holding Tank 1 :7 1 ❑ ❑ ❑ ❑ <br /> lift Pump Tank/Siphon Chamber ❑ ❑ ❑ ❑ ❑ <br /> VIII. RESPONSIBILITY STATEMENT <br /> I,the undersigned,assume responsibility for installation of the onsite sewage system shown n the attached plans. <br /> Plumber's Name:(Print) Plumber's Signature:(No Stamps) / MP/MPRSWNo.: Business Phone Number: <br /> Gam" /1 r,�.e_ /1 k/ j/� //+t ,✓Ez�- .r= j, c 4< <br /> Plumger's Address(Street,City,State,Zip Code): <br /> C/D x SJ <br /> IX. COUNTY/ DEPARTMENT USE ONLY <br /> E]Disapproved Sanitary Permit Fee (Includes Groundwater ate sue lissui gA a Signa ure( amps) <br /> Approved r-1 Owner Given Initial J t��S Marge rec) _ <br /> Adverse Determination ( � ✓ ''-5 <br /> X. CONDITIONS OF APPROVAL/REASONS FO D S PPROVAL: <br /> 6 <br /> P <br /> Fall)-6398(Ft.OY94) DKTRIBUTIUN_ Original o>Cmndy,One copy To:Selaty 88uilafngs Oiveion.Bwuer,Plum r <br />