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�: irfR SANITARY PERMIT APPLICATION Safety andBuilding Water SyBuilding teriSy <br /> O Bureau of stems <br /> 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 i iot less County,��r <br /> than 8 112 x 11 inches in size., ui1CIV 4 <br /> 748 <br /> • See reverse side for instructions for completing this application State Sanitary Permit Numlper <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)]. State Plan I.D.Number <br /> I. APPLICATION INFORMA ON - PLEASE PRINT ALL INFORMATION <br /> d 3 <br /> Prop rt Owner Name Propel Location IrN <br /> 0114 W 1/4,S v T q0 ,N, R 16 E(or W <br /> Property Owner's Mailing Address Lot Number <br /> Block Number <br /> tlu co D . 57 <br /> City,State ZplCode Phone Number Subdivision Name or CSM Number <br /> 12 A IIIu o ( > P 07 <br /> II. PE F B L ING: (ch k one) ❑ State Owned ❑ It Nearest Road <br /> Village n <br /> Public 1 or 2 FamilyDwellin - No.of bedrooms Town F g i�p . go, U <br /> III. BUILDING USE: cif buildin( Cype is public,check alithat apply) Parcel Tax Number(s) <br /> 1 ❑ Apartment/Condo q 1757 <br /> 07- 100 <br /> 2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility <br /> 3 El 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: (Che k only one box on line A. Check box on line B if applicable) <br /> A) 1. ❑ New 2. ❑ eplacement 3.-OReplacementof 4. ❑ Reconnection of 5. E] Repair of an <br /> System 5 stem Tank Only Existing System Existing System <br /> B) ❑ A Sanitary Permit is previously issued. Permit Number Date Issued <br /> V. TYPE OF SYSTEM: (Che(Ik only one) <br /> Non-Pressurized Distribution Pressurized Distribution 1xperimental Other <br /> 115eepage Bed 21 ❑Mound 0❑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 S'J 'JA I FO ATION: <br /> 1. Gallons Per Day 2.A&, p� 3. Absorp.Area 4. Loading Rat 5. Perc. Rate 6. System Elev. 7. Final Grade <br /> (sq.ft.) Proposed(sq.ft.) (Gals/day/sq. .) (Min./inch) Elevation <br /> 765" 8 42 3• Feet yer, 6 Feet <br /> VII. TANK alpaaty <br /> INFORMATION i gallons Total #0f Manufacturer' Name Prefab. Con-Site Fiber- Plastic Exper <br /> Ne Existin Gallons Tanks Concrete strutted Steel glass App. <br /> Tan Tanks <br /> Septic Tank or Holding Tank 17olo 2000 Z C/� p ❑ ❑ ❑ ❑ ❑ <br /> Lift Pump Tank/Siphon Chamber <br /> AV-6 {QI ❑ ❑ ❑ ❑ ❑ <br /> VIII. RESPONSIBILITY STATEMENT 6A&r,154E Sq/1€rQte/7c+ <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 amps) MP PRSW No.: Business Phone Number: <br /> c ." o k�� ' �.f 3'tu 7/.5- %6- 4157 <br /> P mber's Address{Street.Cit ,State, ip Code): <br /> 2-IM rJ I. .4i89s <br /> IX. COUNTY/DEPARTMEP USE ONLY <br /> 1, ❑DisapprovedSanitary Permit Fee (includes Groundwater Date Issued Issuing Agent Signature No tamps) <br /> [ Approved FjOwnerGiver Initial /�0 `ePI <br /> TTT111�" Adverse Determination LO �✓ 7 <br /> X. CONDITIONS OF APPROVAL REASONS FOR DISAPPROVAL: <br /> SBD-6398 in.05,14) DISTRIBUTION: Original to County,One copy To: Salety8 uilUings Division,Owner,Plumber <br />