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�n c� <br /> ••n Safety and Buildings Division <br /> SANITARY PERMIT APPLICATION Bureau of Building Water System <br /> In accord with[LHR 83.05,Wis.Adm_Code 201 E Washington Ave. <br /> 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./ u` <br /> • See reverse side for instructions for completing this application State Sanitary Permit Num ber <br /> The information you provide may be used by other government agency programs2..56 q3/ <br /> [Privacy Law,s. 15,04(l)lm)], ❑Check II rev'ston to previous application <br /> State Plan I.C Number <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION <br /> Property Owner Name Property Location <br /> /0i3 _5om/�l-V- SC-`1/4S`-; 1/4,5 ,;/ T Icy , N, R/Sr E(or)(iy, <br /> Property Owner's Mailing Address Lot Number Iock Number <br /> ,�2E r3c /_3/'ook ltd <br /> City,State Zip Code Phone Number SIutrdivisron Namgag CSM Number <br /> s au er 47- S go j1( )ygk_2083 1 <br /> 1L TYPE OF BUILDING: (check one) ❑ State Owned ❑ city Nearest Road <br /> Public 1 Or 2 FamilyDwelling- No. of bedrooms [IVillage � /� I <br /> Town OF �� /j yrU C <br /> :11. BUILDING USE: (If building type is public,check all that apply) Parcel Tax Number(s) <br /> 1 ❑ Apartment/Condo Ooh 3/, <br /> 2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Outdo r Recreational Facility <br /> 3 ❑ Campground 7 ❑ Merchandise: Sales/Repairs 11 ❑ Restau 'ant/Bar/Dining <br /> 4 ❑ Church/School 8 ❑ Mobile Home Park <br /> 5 [-] Hotel/Motel q 12 E] Service talion/Car Wash <br /> ❑ Office/Factory 13 E] Other: peufy <br /> IV. TYPE OF PERMIT: (Check only one box on line A. Check box on line B, if applicable) <br /> A) 1. n New 2 g Replacement 3. ❑ Replacementof 4 ❑ Reconnectio of 5. Repair of an <br /> System System - Tank Only - Existin S ste Existing System <br /> -------- 9 Y-- <br /> ---------------------- <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 RSeepage 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. ystem Elev. 7. Final Grade <br /> Required(sq- ft.) Proposed(sq.ft.) (Gals/day/sq.ft.) (Min./inch) Elevation <br /> Gallons <br /> G Y3 C> 6 y — _> Feet 96•S— Feet <br /> VII. TANK Capacity <br /> n gallons Total #of Sit <br /> INFORMATION Gallons Tanks Manufacturer's Name Prefab. Con Fiber- Plastic Aper <br /> New Ex istln Concrete struct d Steel glass App. <br /> Tanks Tanks <br /> Septic Tank or Holding Tank ��'� Ic20') El El <br /> Lift Pum pTank/Siphon Chamber f❑fit ❑ ❑ I ❑ ❑ <br /> VIII. RESPONSIBILITY STATEMENT <br /> 1,the undersigned,assume responsibility for installation of the onsite sewage system shown on the attached plans. <br /> Plumber's Name:(Print) Plumber's Signature:ft)Stamps) MP/MPRSW No.: B ismess Phone Number: <br /> ✓, �✓r a�- �� + �� 3Yf—;>_->�� <br /> Plumber's Address(Street,City,State,Zip Code): <br /> IX. COUNTY/ DEPARTMENT USE ONLY <br /> EE]Disapproved <br /> Fanitar Permit Fee (indodeiewundwater ate sue Ii atur (N tamps) <br /> rOVed s chargeteePP ❑Owner Given Initial ( j Adverse Determination ���•+'� to <br /> X. CONDITIONS OF APPROVAL/REASONS FOIr DISAPPROVAL: <br /> sHD-63Ytl(N.01199) DI trRIRUTION. original ro Cnuol y.One<?py To: SJ ,,&RullJing�nrvum".Owner,RlwnFrer <br />