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,�. Safety and Buildings Division <br /> Q <br /> nn SANITARY PERMIT APPLICATION <br /> Bureau ofBugtonAve Water System! <br /> 201 E Washington Ave. <br /> In accord with[LHR 83 05,Wis.Adm.Code P.O.Box 7969 <br /> Madison,W 153707-7969 <br /> • Attach complete plans(to the county copy only)for the system,on paper not less county I ' �� <br /> than 8 112 x 11 inches in size. �v/. <br /> • See reverse side for instructions for completing this application state Sanitary Permit Number <br /> ,;2_5'1e6 � <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)l. State Plan I.DI No by,( <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION <br /> Property Owner Name Property Location <br /> �� �17a v4,S � T C1 ,N, R l� E(or�GVj' <br /> Property Owner's Mailing Address..� 5 /_ Lot Nu berG�jt lock Number <br /> 7,1- <br /> r c+ t <br /> r <br /> Cit ,State e Zip Code Phone Number Subdivision Name or CSM Number <br /> II. TYPE OF BUILDING: (check one) ❑ State Owned U jc� Ne eesst Road / D <br /> Public 0 1 or 2 Family Dwelling- No. of bedrooms -.:Z f4a own of ,,4k v42✓ <br /> III. BUILDINGUSE: (If building type is public,check all that apply) Parcel TaxNumber(s) ' $ <br /> 1 F1 Apartment/ <br /> Apartment/Condo Q °24 <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 /> A) 1. ❑ New 2. XReplacement 3- E] Replacement of 4. ❑ Reconnectiork of 5. ❑ Repair of an <br /> System System ------------- Tank-Only <br /> ---------------Onl Existing Systyym ---Existing System <br /> ------------------------- ---- -- - - F <br /> B) ❑ A Sanitary Permit was previously issued. Permit Number i Date Issued <br /> V. TYPE OF SYSTEM: (Check only one) <br /> NonPressurizedDistribution Pressurized Distribution Experimental Other <br /> 11 5�5eepage 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 /> r <br /> 1. Gallons Per Day 2. Absorp.Area 3. Absorp.Area 4. Loading Rate 5. Perc. Rate 61 System Elev. 7. Final Grade <br /> Required (sq. ft.) Proposed(sq.ft.) (Gals/day/sq. ft.) (Min./inch) Elevation <br /> Feet fes, y Feet <br /> VII. TANK Capacity $to <br /> INFORMATION n gallons Galloal Manufacturer'sTa ks Manufacturer's Name Concrete e C n- Steel glass Plastic Aper <br /> New Existin strgcted <br /> Tanks Tanks1 <br /> Septic Tank or Holding Tank / W C El El El <br /> L rft Pump Tank[Siphon Chamber 1:1 El El 11 <br /> VIII. RESPONSIBILITY STATEMENT <br /> 1,the undersigned,assume responsibility for installation of the onsite sewage system shown n the attached plans. <br /> Plumber's Name:(Print) Plumber's Signature:(No Stamps) MP/MPRSWNO: Business Phone Number <br /> -/�, � Z�, Z/"-, his- 39�-�aF61 <br /> Plumber's Address(Street,City,State,Zip Code): i <br /> IX. COUNTY/ DEPARTMENT USE ONLY <br /> �1, <br /> El Disapproved Sanitary Permit Fee_((Inq de,Groundwater ate s ue Issu gAgen ign ore( o amps) <br /> �A roved cagelee) <br /> pp ❑Owner Given Initial I /�r 5 �� <br /> Adverse Determination / <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DIP7 AL; <br /> 5up-6398(x.05/99) ]V�/ DKIAI9UTION_Originalto(ouNy,Oneo4),To-S�lety BOuBdinga Dlaiuon,nwner,Plum r <br />