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Safety and Buildings Division <br /> SANITARY PERMIT APPLICATION <br /> Bureau of Building Water System. <br /> O201 E Washington Ave. <br /> In accord with[LHR 83 05,W is.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 8112 x 11 inches in size. <br /> • See reverse side for instructions for completing this application State Sant tary <br /> PeeCrrt p <br /> Number '15 <br /> The information you provide maybe used by other government agency programs E]Check revision eviuus application <br /> [Privacy Laws. 15.04(1)(m)I. State Plan LD.Number ���� <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION ��J25 <br /> Propert Owner Name Property Location �/ <br /> orJ C2 1/4 1/4,Sa[y C ,N, RE (or V3 <br /> Prop rty Owner's Mailing Address Lot Number <br /> 1Q v' <br /> City, tate Zip Code Phone Number kttbdivismnT&mn rCSM Numb r <br /> II. TYPE OF BUILDING: (check one) ❑ State Owned ❑ cily �[ rNere�stRoadPublic 1 or 2 Famil Dwellin - No.of bedrooms oZ 10 Iowan ofK <br /> t Parcel Tax Number(s) <br /> Il. BUILDINGU E: (If building type is public,check all that apply) L) Ip1 oa� l� <br /> 1 E] !;""S Apartment/Condo N0 t <br /> 2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility <br /> 3 ❑ Campground 7 ❑ Merchandise: Sales/Repairs 11 ❑ Rest 3urant/Bar/Dining <br /> 4 ❑ Church/School 8 ❑ Mobile Home Park 12 ❑ ServiceStation/Car Wash <br /> S ❑ 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 /> 060 — _ Feet Feet <br /> Capacrt <br /> VII. TANK n allon, Total #Of Prefab. Site Fiber- Plastic Exper <br /> INFORMATION Gallons Tanks Manufacturer's Name Concrete CO"- Steel glass App <br /> New ]Existings rutted <br /> Tanksl Tanks p� <br /> r Holding Tank eioo vooe) / S' 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 on the attached plans. <br /> Plumber's Name.(Print) / Plumber's <br /> ignature (No mps) /MPRSW NNoo.: Business Phone Number: / <br /> 5 O( L/✓ CSC ;'-^'� rG.'' � `f1/ :�`�'c� <br /> PI bei s Ad ress(Street,City,State,Zip Codi): <br /> IX. OUNTY/ DEPARTMENT USE ONLY <br /> E]Disapproved Sanitary Permit Fee ndudeiGroundwarer ate Issue Is uing Agent Signature(No Stamps) <br /> Approved mrcbaei ee) <br /> pp ❑Owner Given Initial '� vM <br /> Adverse Determination <br /> ONDITIONS OF APPROVAL/ REASONS FOR DISAPPROVAL: <br /> Sitn-t398(it.OY94) rt4RIHIJTION orlginntto Cmuity,Onec"py To. S+rely BflullAlny nimuon,Owner,Pl Inbar <br />