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C , <br /> ..:::e:ea. Safety and BuildinDivision <br /> SANITARY PERMIT APPLICATION Bureau a Building Water Systems <br /> r�`��.:�7�7 201 E.Washington Ave. <br /> 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 County <br /> than 8 1/2 x 11 inches in size. 14 <br /> • See reverse side for instructions for completing this application State Sanitary Permit u ber <br /> � 9 ?3 <br /> The information you provide may be used by other government agency programs ❑Che II revision to previous application <br /> (Privacy Law,s. 15-04(1)(m)) State Plan LD-Number C/ / <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION <br /> Property Owner Name , / Property Location <br /> MILTI)KI E , W EI (,. 1/4 1/4,5 T N, R (or)W <br /> Property Owner's Mail in Address Lot Numbe Block Number - <br /> 0 0 E LVD. U1. 9 <br /> City,5tate Zip Code Phone Number Subdivision Name or CSM Number /�O <br /> ND <br /> MAI`• 30 (Liz )yz1- ISS W6159 Su - �+ d <br /> II. TYPE OF BUILDING: (check one) ❑ State Owned ❑ cityNearest Road p.' <br /> El I 0� ���8�� S�s�- Iw <br /> ❑ Public 1 or 2 FamilyDwelling- No. of bedrooms Town of L K TV <br /> ill. BUILDING USE: (If buildingtype is public,check all that apply) Parcel Tax Number(s) <br /> 1 E] Apartment/Condo ON `90Z5 O' 100 <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.ji Replacement 3. ❑ Replacement of 4- ❑ Reconnection of 5. ❑ Repair of an <br /> System System Tank Only Existing System Existing 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 41� folding Tank <br /> 12 E]Seepage Trench 22 F1 In-Ground Pressure 4 ❑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. Pert. Rate 6. Syste Elev. 7. Fina Grade <br /> Require ft.) Propose sq. ft.) (Gals/d /s ft.) (Min. ch) Ele Ion <br /> Feet <br /> VII. TANK Capacity Isite <br /> INFORMATION in gallons Total #of Manufacturer's Name Prefab Con- Fiber- <br /> Plastic Aper- <br /> Gallons Tanks Concrete Steel g pp <br /> New Existingstrutted <br /> Tanks Tanks �1 <br /> Septic Tank or Holding Tank 20 67 A VJ ❑ ❑ Q El <br /> Lift Pump Tank/Siphon Chamber L Il El ❑ 0-1 ❑ 11 <br /> VIII. RESPONSIBILITY STATEMENT <br /> t,the undersigned,assume responsibility for installation of the onsite sewage system shown on the attached plans. <br /> Plumber's Name:(Print) Plumber's Signature:(No 5 mps) MP/MPRSW No.: Business Phone Number: <br /> o <br /> z6 s- s <br /> umber's Address(Street,City,State Zip Code): <br /> w <br /> IX. COUNTY/ DFPARTMEWT USE ONLY <br /> ❑Disapproved Sanitary Perml Fee (Includes Gro ondwater ate I Lie Issuing Age t Sig tut a ps) <br /> rcharge lee) <br /> pproved <br /> F1 Owner Given Initial �� 97 <br /> Adverse Determination <br /> X. CONDITIONS OF APPROVAL/ REASONS FOR DISAPPROVAL: <br /> SBU-6398(8.05/94) DISMOUIIDN. Original to Cminly.one copy fo: Safety 9 Boddings Division,owner,Piwnber <br />