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nod Buildings Division <br /> SANITARY PERMIT APPLICATION Bureau of Building Water System <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 Coun�ty <br /> than 8 112 x 11 inches in size. frc: p( <br /> • See reverse side for instructions for completing this application e.5L ,�3 .tJ <br /> 666 State—Sanitary Permit Number <br /> q, <br /> l7ao ��/os�g <br /> The information you provide maybe used by other government agency programs ❑Check it revision to previous application <br /> tPrivacy Law,s 15.04(1)(m)L NState Plan I.D.Number h <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORM &O-N DV <br /> Prop�j rtyOwner Name roper ion <br /> 00,4 le- /L)dYe So tiL S /7 TSS ,N, R/S'E(or)� <br /> Property Owner's Mailing Address of Nu Block Number <br /> 5-0 /yi iQ1j, <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> -, <br /> II. TYPE OF BU DING: (check one) E] State Owned ❑ city Nearest Road <br /> or 2 Familywelling- No.of bedrooms town or <br /> El Village , n� e <br /> Public <br /> 111. BUILDING USE: (If building type is public,check all that apply) Parcel TaxNumber(s) ) <br /> 1 ❑ Apartment/Condo O —a 7 ` U - OO <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 Weplacement 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®,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 13. Absorp.Area 4. Loading Rate 5. Perc. Rate 6. System Elev. 7. Final Grade <br /> Required(sq. ft.) Proposed(sq.ft.) (Gals/day/sq. ft.) (Min./inch) c/ Elevation <br /> ,3® C) 5 73 r 8 77l Feet Feet <br /> TANK Capacct <br /> VII. INFORMATION in alio s Total #of Manufacturer's Name Prefab. Con- Steel Fiber- plastic Exper <br /> New Existin Gallons Tanks Concrete strutted glass App <br /> cTTanks Tanks <br /> Septic Tank or Holding Tank 80tJ Fee <br /> e a s /4-e,-) ❑ ❑ ❑ ❑ ❑ <br /> Lift Pump Tank/Siphon Chamber ❑ ❑ ❑ ❑ ❑ ❑ <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:(Priv Plumber's Signature:(No Stamps) MP/MPRSW No.: Business Phone Number: <br /> Plumber's Address(Street,City,State,Zip Code): <br /> IX. COUNTY/ DEPARTMENT USE ONLY <br /> ❑Disapproved Sanitary Permit Fee (includes Groundwater ate Issued Issuinatur amps) <br /> roved urcharge hee) <br /> pp ❑Owner Given Initial /� � � 3 ' G�� <br /> Adverse Determination / <br /> X. CONDITIONS OF APPROVAL/ REASONS FOR DISAPPROVAL: <br /> SND-6398(R 05/94) DISTRIBUTION: Original to)moray,One ropy To 5utety&Bui Wings Dv.-soon,Owner,Plumkuxr <br />