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_ <br /> Oil IN) Kfety L,d Buildings Division <br /> SANITARY PERMIT APPLICATION Bureau of Building Water systems <br /> moi■ ■ ■'■ 201 E.Washington Ave. <br /> ��■�"�� - <br /> In accord with ILHR 83 05,Wis.Adm Code P.OBox 7969Madison,WI 53707-7969 <br /> • Attach complete plans(to the county copy only)for the system,on paper not less Countyu rN1-44- <br /> 2 / <br /> than 81/z x 11 inches in size. ,CSSJ l� <br /> State Sani�y,Permit Nymber <br /> ■ See reverse side for instructions for completing this application 3 �(�lj' <br /> The information you provide may be used by other government agency programs ❑Check it revision to previous application <br /> (Privacy Law,s. 15.04(1)(m)I. State Plan I.D.Number <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION I I rl <br /> Property Owner Name / / ! P op ty Location <br /> C O�b erYa'i..7 1 �_1/4,S.2c? T.3 7 ,N, R/tf E(or)(0 <br /> Property Owner's Mailing Address Lot Number Block Number <br /> City,State Zip Code Phone Number SubdW4i@o4j, me or CSM Number <br /> Gr tS�u7 S4$f o ( )ypg--�7�Y ;2 <br /> II. TYPE F ❑ vii ILDING: (check one) ❑ State Owned Nearest Road <br /> // age <br /> Public 1 or 2 FamilyDwelling-No.of bedrooms 1� Town of r�l- LRke <br /> III. BUILDING USE: (If building type is public,check all that apply) Parcel TaxNumber(s) <br /> 1 ❑ Apartment/Condo <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 /> New 2. eplacement 3. E] Replacementof 4- El Reconnection <br /> System ystem Tank Only ------------ 9 yof 5. ❑ Repair Of an <br /> A) 1- [:I New System Existing System <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 41XHolding 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 /> loo � meet Feet <br /> ;Se;pticTank <br /> ( NK CapautY Site <br /> in gallons Total #of Manufacturer's Name prefab. Con- Steel Fiber- plastic Aper <br /> ORMATION New Existin Gallons Tanks Concrete strutted glass App. <br /> T�anks Tanks � x ❑ ❑ <br /> or Holding TankLi <br /> ift Pump Tank/Siphon Chamber El El ❑ <br /> L <br /> VIII. RESPONSIBILITY STATEMENT <br /> I,the undersigned,assume responsibility for installation of the onsite sewage system shown on the attached plans- <br /> Plumber nature:(N Stamps) MP/MPRSW No.: Business Phone Number: <br /> Plumber's Name:(P�r jnt) g <br /> (/")f 't_ 114 o! ` o` d <br /> Plumber's Address(Street,City,state,zip Code): <br /> IX. COUNTY/ DEPARTMENT USE ONLY <br /> ❑Disapproved Sanitary Permit Fee Onaudes groundwater ate ssue Issuing Agept Stnatu e(N ps) <br /> Surcharge fee) <br /> ;�Approvecl ❑Owner Given Initial /50 00 <br /> Adverse Determination f 76&-- °23 4 <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> Sen-6398(k.OS194) <br /> DISTRIBUTION'. Original to Cuurj ,One cuPy To: Safety&&uildiny>Dm_wn,Owneq Plumber <br />