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�}-l2C,t17n-� <br /> Safety and Buildings Division <br /> �■�nn SANITARY PERMIT APPLICATION Bureau of Building Water Systems <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. E94elnc� a33�0 <br /> • See reverse side for instructions for completing this application State San_i`tayryy PPPe)rrm"umr/be r <br /> The information you provide may be used by other government agency programs ❑Ct i revision It4'on to(C/•p��r/eve/moi/oju�s'a'p'pl'ication <br /> (Privacy Law,s. 15.04(1)(m)]. x.D <br /> State Plan I.D.Number <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION <br /> Property Ow e t S rope cation <br /> s �i4ec� �'yw$asr ti4 1/4,S T 3f ,N, R/*I E(or6l G <br /> Property Owner's Mailirig Address Lot Number Block Number <br /> City,Sta Zip Code one Number Subdivision Name or CSM Number <br /> ;;: for S ( ?Ag Z <br /> II. TYPE OF BUILDING: (check one) ❑ State Owned ❑ CityNearest Road <br /> Public 1 or2Family Dwelling- No. of bedrooms L E] Village ys<, <br /> own OF 7-� O 40"M <br /> III. BUILDING USE: (If building type is public,check all that apply) Parcel TaxNumber(s) <br /> 1 ❑ Apartment/Condo OZil— 3/36- O/—v00 <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 )eNew 2, ❑ Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an <br /> ---,K--System -- System -- - Tank Only---------------Existing System g _y __________ExlstingSystem <br /> B) ❑ A Sanitary Permit was previously issued. Permit Number Date Issued <br /> V. TYPE OF SYSTEM: (Check only one) <br /> Non-Pressurized Distribut n Pressurized Distribution Experimental Other <br /> 11 Seepage Bed (Lt + 21 E]Mound 30❑Specify Type 41 El Holding Tank <br /> 1X❑'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. 1 7. Final Grade <br /> .[ Required (sq. ft.) Proposed(sq.ft.) (Gals/day/sq. ft.) (Min./inch) Elevation <br /> KSO 41-3 6$448 , -tiorp4 9JIO Feet 977.q Feet <br /> VII. TANK Capacity <br /> INFORMATION in gallons Total #of Manufacturer's Name Prefab. Site Fiber- Exper <br /> New ExistingGallons Tanks Concrete CO" Steel glass Plastic App <br /> strutted <br /> Tanks Tanks <br /> Septic Tank orHnlrlinnTank /600 000 <br /> Lift Pump TankJS Imo"vcc 4&740 pd ❑ EE31 ❑ F-1 0 <br /> VIII. RESPONSIBILITY STATEMENT <br /> I,the undersigned,assume respo ibility for install on of the onsite sewage system shown on the attached plans. <br /> Plumber's NarMELM9SOILTESTIN Plu UsSignatur (No Stamps) [Mt! PRS .. Business Phone Number: <br /> N6228 County Line Rd. �a <br /> Plumber's Addre rt a de): <br /> (7151635-7482 <br /> IX. COUNTY/ DEPARTMENT USE ONLY <br /> ❑Disapproved Sanitary Permit Fee (1, ude5eroundwnter Date Issued Issuing geof Signature(No St ps) <br /> AApRroved []Owner Given Initial narge I ee) <br /> Adverse Determination �� ���� � f <br /> X. CONDITIONS OF APPROVAL/REAS NS FO DISAPPROVAL: <br /> off- <br /> SBD-6398(R.05/94) DISTRIBUTION: Original to County,One copy To: Safety 8 fluildinrya Division,Owner,Plurnbar <br />