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Safety and BuDivision <br /> Bureau of Building Water Systems <br /> •-=""%�� SANITARY PERMIT APPLICAT 201 EWashington Ave. <br /> ri7Lf1�7 �1I P.O.Box 7969 <br /> In accord with(LHR 83 05,Wis.Adm.CO �` Madison,WI 53707-7969 <br /> • Attach complete plans(to the county copy only)for the system,on pa er r> � <br /> than 8112 x 11 inches in size. w <br /> State Sanitary t f976 <br /> • See reverse side for instructions for completing this application (((JJ15 <br /> The information you provide may be used by other government agency programs ❑check if revision o previous application <br /> (Privacy Law,s- 15.04(1)(m)]- State Plan I.D.Numb <br /> 1. <br /> �� <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION (� <br /> Propert Owner Name Property Location <br /> /10--o 0-9 114 114,Sa3 T T� .N, R! E(o W <br /> Property Owner's Mailing Addless er Block Number <br /> s' -7 A-v 6, L L <br /> City,State / zip Code Phone Number Subdivision Name or CSM Number <br /> G' f1'UfSFa O S <br /> II. TYPE F BU DING: (check one) ❑ State Owned ❑ city Nearest Road <br /> I <br /> Lj Public 1 or 2 FamilyDwelling-No.of bedrooms V Town OF (0 <br /> III. BUILDING USE: (If building type is public,check all that apply) <br /> Parcel Tax Number(s) <br /> c 5d3Z73 0 4(z 5'/d <br /> 1 ❑ Apartment/Condo <br /> 2 ❑ 10 Assembly Hall 6 ❑ Medical Facility/Nursing Home 11 ❑ Outdoor Recreational Facility <br /> 3 El Campground 7 [3 Merchandise: Sales/Repairs E] Restaurant/ 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 /> Replacement of 4. Reconnection of 5. ❑ Repair of an <br /> A) 1 New 2. ❑ Replacement 3. ❑ p ❑ E"Syxfstin System <br /> stem System ------------- Tank OnlY-------------------g---------------Ex)stfngSystem <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,�5.Mound 30❑Specify Type 41 ❑Holding Tank <br /> 22 In-Ground Pressure 42❑Pit Privy <br /> 12 E]Seepage Trench ❑ 43 E]Vault Privy <br /> 13 E]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. 7.Elevlation nal rade <br /> Required(sq. ft.) Proposed(sq.ft.) (Gals/day/sq./sq. ft.) (Min./inch) 4?V <br /> ®o v�S� x,75 .Z / d� Q Feet lel,;2— Feet <br /> VII. TANK Capacity Site Fiber- Exper <br /> in gallons Total #of Manufacturer's Name Coneebte Con- Steel glass Plastic App <br /> INFORMATION New Existin Gallons Tanks strutted <br /> Tanks Tanks <br /> Septic Tank or Holding Tankv 75-0 ) El El El <br /> ❑ ❑ <br /> Lift Pump Tank/Siphon Chamber Jd� _15r29� <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: DStamps) <br /> el� <br /> MP/MPRSW No.: Business Phone Number: <br /> "Z".2- <br /> Plumber's Address(Street,City,State,zip Code): <br /> +U O c^ <br /> IX. COUNTY/ D FARTMENT USE ONLY <br /> ❑Disapproved Sanitary Permit Fee ('"`1paesc(ovndwater ate 1 sue Issuing A en ignature( S ps) <br /> ]Surcharge fee) <br /> T1Wproved ❑Owner Given Initial L/ a29 <br /> Adverse Determination <br /> X. CONDITIONS OF APPROVAL/REASONS FOR ($APPROVAL: <br /> Snn-639h(ft.05/94) DISTRIBUTION'. Original to Cnur,ty,One copy To: Safety 8 Buildings Division,owner,Vlurnwf <br />