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Safety and Buildings Division <br /> �+ Bureau of BuildingWater System. <br /> ter• SANITARY PERMIT APPLICATION 201 E.Washingt Ave <br /> In accord with[LHR 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 <br /> than 81/2 x 11 inches in size. Cid <br /> • See reverse side for instructions for completing this application s eSanita Permit Number <br /> Cicreiba <br /> The information you provide may be used by other government agency programs E)Check it re cion Io previous application <br /> [Privacy Laws. 1 504(1)(m)I- <br /> State Plan I. .Number <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION <br /> Prop.w4 Owner Name Property Location <br /> KAK o LA Fso1/4 1/4,5 7 T N, R E(or)(@ <br /> Property wner's Mailin Address Lot Number Block Number <br /> SIs IM O 5T - I� <br /> City,Stat1 - Zip Codes/ (P otZNu ber �35ubdivis .Kiame or CSCMN on ?r "NWearest <br /> (0 II. TYPE BUILDING: (check one) ❑ State Owned ❑ citoadp❑ Public 1or2Famil Dwellin - No. ofbedrooms V.aneoF S� 96 Rp" <br /> 1cel Taxmber(s) <br /> N <br /> .I1. BUILDING USE: (If building type is public,check all that apply) <br /> Par <br /> ODI� <br /> 1 F1 Apartment/Condo ^ ^^ O <br /> 2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility <br /> 3 ❑ Campground 7 ❑ Merchandise: Sales/Repairs 11 ❑ Resta rant/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) 1.10"New 2. E] Replacement 3. El Replacementof 4. E] Reconnecti n of 5- E] Repair of an <br /> /'�`System System Tank Only ExistingSyst m Existing System <br /> ----------------------------------------------------------------------------------------------- <br /> B) ❑ A Sanitary Permit was previously issued. Permit Number Date Issued <br /> V. TYPE OF SYSTEM: (Check only one) <br /> NonPressurizedDistribution Pressurized Distribution Experimental Other <br /> 11 1Seepage Bed 21 <br /> IE] 30❑Specify Type 41 [-] Holding Tank <br /> 1 ❑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 System Elev. 7. Final Grade <br /> tA <br /> Requir d (sq. ft.) Pro osed(sq. ft.) (Gals/day/sq.ft.) (Min./inch) Elevation <br /> Pj Feet •0 Feet <br /> Ca aut <br /> VII. INFORMATION in allons Total #of Manufacturer's Name Prefab Site Fiber- Exper <br /> g Gallons Tanks Concrete Steel glass Plastic App <br /> New Existin str cted <br /> Tanks I Tanks <br /> Septic Tank or Holding Tank (7 �� ❑ ❑ ❑ ❑ <br /> t lft Pump Tank/Siphon Chamber ❑ ❑ ❑ ❑ ❑ <br /> VIII. RESPONSIBILITY STATEMENT <br /> I,the undersigned,assume responsibility for installation of the onsite sewage system shown I In the attached plans. <br /> Plumber's Name: (PrintN Plumber's Signature: N tamps) MP/MPRSWNo.. Business Phone Num er. <br /> i pP ZL s- �b66 Sl <br /> PI mber's Address(Street,City,State, ip Code): <br /> z s 0.6 roz W[ sk8�3 <br /> IX. COUNTY/ DEPARTMENT SE ONLY <br /> ❑Disapproved FS4naa�ryermit Fee (Indudes Groundwater ate Issue Issui gAgent Sign ure(N Stamps) <br /> ftApproved rOVed r arge tee) <br /> 'S' pp []Owner Given Initial <br /> Adverse Determination 1JV <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SRU-4398(R.W94) DISTRIBUTION. Original to eoula,One mPY Ta. S.defy B Rui Lling�Division.flwer.Vlum r <br />