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Safety and Buildings Division <br /> SANITARY PERMIT APPLICATION Bureau of Building Water Systems <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 not less count �/// <br /> than 8 112 x 11 inches in size. t^Alt <br /> • See reverse side for instructions for completing this application State Sanitary <br /> )Permit <br /> ®Nu ber <br /> The information you provide may be used by other government agency programs ❑ <br /> I Privacy Law,s. 15.04(1)(m)] Check it revision to previous application ` <br /> . <br /> State Plan I.D.Number <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION I /U <br /> Property Owner Na a Property Location <br /> ,04 <br /> 57Z(=1/a 1/a,S 7 T 3'$` ,N, R/S fir)W <br /> Property Owner 5 ling Address Lot Number _ Block Number <br /> Cit , tate Zip Code Phone Number Subdivision Name or CSM Number <br /> s We'S (7/ 6�o;P7'8 <br /> II. TYPEOF BUILDING: (check one) E] State Owned 0 Cit Nearest Road <br /> Public 1 or 2 FamilyDwelling-No.of bedrooms vii age 1 �� E� <br /> Town OF f� P <br /> III. BUILDING USE: (if buildmgtypeispublic,checkallthatapply) Parcel Tax Number(s) Q <br /> 1 ❑ Apartment/Condo vg/jq - ,;R;Ze 7 —e�— /©© <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 0 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. ❑ 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 ❑ Holding Tank <br /> 12,M 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 /> Required(sq. ft.) Proposed(sq. ft.) (Gals/da sq.ft.) (Min-/inch) Elevation <br /> T1115irly 1 <br /> 1 9 70�-? Feet 94 A <br /> Feet <br /> TANK Ca aut <br /> VII INFORMATION in gallons Total #of Manufacturer's Name Prefab Site Fiber- Exer <br /> New ExistingGallons Tanks Concrete Con- Steel glass Plastic App <br /> Tanks Tanks <br /> structed <br /> Septic Tank or Holding Tank Q tq-4CO 241 ® ❑ 1 ❑ EJ ❑ El <br /> Lift Pump Tank/Siphon Chamber ❑ El Ej ❑ <br /> VIII. RESPONSIBILITY STATEMENT <br /> I,the undersigned,assume responsibility for installation of the onsite sewage system shown on the attached plans- <br /> Plum er's Name:(Print) Plum is ignatMP/MPRSW No.: Business Phone Number: <br /> w <br /> � �c M r?, urYe: S mp3�7 g� 2 �-rit, <br /> Plumber's Address(Street,City,State,Zi Code): 5 9/_0a 7/ <br /> OIL <br /> IX. COUNTY/ DEPARTMENT USE ONLY <br /> ❑Disapproved Sanitary Permit Fee UndudesGroundfee)water, ateIssuedIssuing AgentSignatu e Stamps) <br /> pproved ❑Owner Given Initial °rcharge <br /> Adverse Determination / O 71/�S�Q <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> 57a.-N <br /> SRO-6398(R.OS/94) DISTRIBUTION. Original m Cnura y,One copy To Safely 8 Buildings Division,Owner,Plumber <br />