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tll\ Cir )l� <br /> Safand Buildings Division <br /> ^■� ••^ SANITARY PERMIT APPLICATION BureetyauofBuildingWaterSystems <br /> r�•L�7•'• 201 E-Washington Ave. <br /> In accord with[LHR 83 05,Wis.Adm.Code P.O.Box 7969 <br /> Madison,W 153707-7969 <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 Sanitar Permit Number <br /> s 0 6;2— <br /> Oct. <br /> - (!� <br /> The information you provide may be used by other government agency programs ❑Check it rev Rion to previous application <br /> [Privacy Law,s. 15.04(1)(m)l. State Plan I.D'r NurDborr <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION <br /> Propert Owner Name Property Location <br /> AN U 4 4,s Z�I T , l ,N, R 17 E(or)Q <br /> Propertwner'sM fling Address Lot Number $lock Number <br /> w 7 <br /> City,State L Code Phon Nu er Subdivision Nam a rCSMNumber <br /> L( W l - 5P Sao )G6' I CSM a o a <br /> II. TYPE F BUILDING: (check one) ❑ State Owned ❑ ity Nearest Road <br /> ❑ Village —I <br /> Public 1 or 2 Famil Dwellin - No. of bedrooms —3 Town of -Sw 1315 <br /> W 1 7 <br /> III. BUILDINGUSE: (If building type is public,check all that apply) Parcel Tax Numbers)) <br /> 1 ❑ Apartment/Condo 3�` a �� � ]� <br /> 2 F-1AssemblyHall 6 E] Medical Facility/Nursing Home 10 E] Outdoor Recreational Facility <br /> 3 ❑ Campground 7 ❑ Merchandise: Sales/Repairs 11 ❑ Restautant/Bar/Dining <br /> 4 ❑ Church/School 8 ❑ Mobile Home Park 12 ❑ Servico Station/Car Wash <br /> 5 ❑ Hotel/Motel 9 ❑ Office/Factory 13 ❑ Other:Lecify <br /> IV. TYPE OF PERMIT: (Check only one box on line A. Check box on line B, if applicable) <br /> A) 1. RNew 2_ ❑ Replacement 1 ❑ Replacementof 4. ❑ Reconnectio(tof 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 /> Nom 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. Fi <br /> Required (sq. ft.) Pro osed(sq.ft.) (Gals/day/sq. ft.) (Min./inch) Elevation <br /> nal Grade <br /> 45D7 Nlh %p <br /> 3 $ , 7•Z Feet Feet <br /> TANT Capaat <br /> VII. INFORMATION in llons Total r of Prefab. Site Fiber- Aper <br /> g Gallons Tanks Manufacturer's Name concrete con- Steel glass Plastic App <br /> New Existin strutted <br /> Tanks Tanks <br /> Septic Tank or Holding Tank QV4 19 Il ❑ 1:1 El <br /> Lift Pump Tank/Siphon Chamber ❑ El El 11 <br /> VIII. RESPONSIBILITY STATEMENT <br /> I,the undersigned, assume responsibility for installation of the onsite sewage system shown c n the attached plans. <br /> Plumber's Name: (Print) Plumber's Signature (No tamps) MP/MPRSWNo.. Business Phone Number: <br /> KI4AICO AegJAIS wed w 3y2-.G s 866- l� 7 <br /> Pumber's Address(Street,City,St te,zip Code): <br /> � 776o w 3Swas 6Z W I. 8�3 <br /> IX. COUNTY/ DEPARTMENT USE ONLY <br /> ❑Disapproved Sanitary Permit Fee (1,01 des Gr.0"d"' w ate s ue Issui,g Agent ign ure N tamps) <br /> Surcharge lee) <br /> }L,�a(p,Approved ❑Owner Given Initial Sb <br /> [ Adverse Determination �' 00 <br /> X. CONDITIONS OF APPROVAL/ REASONS FORDISAPPROVAL: <br /> i <br /> SBD-6398(h.W94) DMRIBUTION. Onginalm(nurdy,One wpy To. SJetyd BudJinge Diai.mn,Owneq plum r <br />