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nd <br /> Divis <br /> on <br /> �:�■:: SANITARY PERMIT APPLICATION Safety ofBuilldinggWaterl <br /> Bureau of Building System, <br /> In accord with ILHR 83 05,Wis.Adm_Code 201 E Washington Ave. <br /> P.0 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 8 112 x 11 inches in size. )(0 ?j7 <br /> • See reverse side for instructions for completing this application State Sanitary Permit Number <br /> it �J <br /> The information you provide may be used by other government agency programs 3O/ 6 J 0 <br /> (Privacy Law,s. 15.04(1)(m)]. ❑Check revision to previous application <br /> State Plan I.D.Number <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION <br /> AM- <br /> Property Owner Name `` Property Location <br /> N�M ®�1 5 ,cj /UL=1/4nJE1/4,S T ,N, R )_T (or)® <br /> Property Owner's Mailing Address A Lot Number Block Number <br /> City, tat To�_,6r' <br /> ip Code Phone Number Subd�ainefl-FV.iwle or CSM Number <br /> daK ��e ,11is8 (61;2 ) _ 3 v <br /> 11. TYPE OF BUILDING: (check one) ❑ State Owned ❑ c1tv t Nearest Road <br /> El Public or 2 Famil Dwellin - NoT <br /> .of bedrooms a Li Village <br /> Town 0Fs'Cc1/� <br /> III. BUILDING USE: (if building type is public,check all that apply) y Parcel TaxNumber(s) <br /> f 6L - �9- a/ <br /> 1 ❑ Apartment/Condo <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 /> S ❑ 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. gNew 2. ❑ Replacement 3. Replacement of <br /> 'S ❑-- -- --- -q. ❑ Reconnection of S. ❑ Resting System <br /> ----__ <br /> 'System - - System -- -- Tank Only Existin System Existing S stem <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 Weepage 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. System Elev. 7. Final Grade <br /> O Q Re uiirred (sq.ft.) Propl��sq. ft.) (Gall sq. ft.) (Min./inch) Elevation <br /> la 7 9G <br /> - <br /> VII. TANK Capacity Feet29,1 Feet <br /> INFORMATION in gallons Total #of Manufacturer's Name Prefab. Site Fiber- Exper. <br /> New Existin Gallons Tanks Concrete Con- Steel glass Plastic App. <br /> Tanks Tanks strutted <br /> Septic Tank or Holding Tank 70O 80 O ,S Ai4e l 9 ❑ <br /> Lift Pump Tank/Siphon Chamber E] E] E El ❑ <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: No Stamps) MP/MPRSW No.: Business Phone Number: <br /> 0 y9- 2,-7 S <br /> Plumber's Address(Street,City,State,Zip Code): <br /> ,fie <br /> IX. CO TY/ DEPARTMENT USE ONLY <br /> ❑Disapproved Sanitary Permit Fee (lndodesGroundweter ate Issue Issuing A t Signature(No S lips) <br /> Approved ❑Owner Given Initial 1� a,9ereel ^�� O <br /> Adverse Determination c >I lel 7 <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SND-639tl(R.OSP)4) DMRIRUTION: 0149111-11 0 Cnuaty.One Copy To: Safety&Buildings nivrjon,Owner,Plumwr <br />