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Safety and Buildings ivision <br /> SANITARY PERMIT APPLICATION Bureau Building Water Systems <br /> �■ 201 E.Waashington Ave. <br /> �t��,.nn 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 M��J , <br /> ��than 8 1/2 x 11 inches in size. V Permit umb rSee reverse side for instructions for completing this application (®The information you provide may be used by other government agency programs i n o previD s ap�tion <br /> (Privacy Law,s. 15-04(1)(m)1. . umberI. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION CPropert Owner Name Property Locatio /s KR C ,SO1 A S E 1/4, R ,N, R b E(o W <br /> Property Owner's Mailin Addr s Lot Number lock Numbe� <br /> I,J ST- <br /> Cit ,State I Zip Con Phone Number Subdivision Name Zr M Num er <br /> S Z_ (-k ) <br /> State Owned yy Nearest Road <br /> II. TYPE OF BUILDING: (check one) ❑ o vlage � <br /> Public 1 or 2 FamilyDwelling- No.of bedrooms 2 own of �R�� <br /> III. BUILDING USE: (If building type is public, Parcel Tax Number(s) <br /> c,checkallthatapply) / J <br /> 0/9- 33a-3 - ©l <br /> 1 ❑ Apartment/Condo <br /> 2 El Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 El Outdoor Recreational Facility <br /> 3 E] Campground 7 F1 Merchandise: Sales/Repairs 11 E] RestaurantBar/Dining <br /> 4 F1Church/School 8 E] 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. Replacement 3. ❑ Replacement of 4. E] Reconnection of 5- E] Rep <br /> of an <br /> A) 1. ❑ Tank Only Existing System------------Existing System <br /> ------System --------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 /> 22,gIn-Ground Pressure 42 El Pit Privy <br /> 12 E]Seepage Trench 43❑Vault Privy <br /> 13❑Seepage Pit <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. Ele Final Grade <br /> Re fired(sq.ft.) Proposed(sq.ft.) (Gals/day/sq.ft.) (Min./inch) Z Feet .O Feet <br /> 3DO Goo folci •S <br /> VII. TANK Capacity site Fiber- Exper <br /> in gallons Total #of Manufacturer's Name Prefab. Con- Steel lass Plastic App <br /> INFORMATION New Existin Gallons Tanks concrete strutted g <br /> Tanks Tanks 5 / —ff ff El El <br /> Septic Tank or Holding Tank ❑ 0— <br /> ❑ Ej El <br /> Lift Pump Tank/Siphon Chamber JW <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 Signature: NoS amps) <br /> MP/MPRSW No.: Business Phone Number: <br /> s I- of 342L is Soc - I S <br /> PI mber's Address(Street,City State,Zip Code): v <br /> 3 <br /> IX. COUNTY/DEPARTMENT 11.115E ONLY <br /> Disapproved Sanitary Permit Fee <br /> (includes Groundwater ate ue IssuinAAe t e oStamps) <br /> ❑ pp Surcharge Fee) <br /> proved ❑Owner Given Initial (� �� <br /> Adverse Determination <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SND-6398(R.OV94) DISTRIBUTION: Original to county.One<oPY To: Safety 8 RuilUings Division,owner,Plumber - <br />