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Safety and Buildings Division <br /> Bu eau eau of BuildingWaters stem. <br /> r.■aL■■IR SANITARY PERMIT APPLICATION 201 E Washington Ave. y <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 county t <br /> than 8 112 x 11 inches in size. lm q (d <br /> • See reverse side for instructions for completing this application State SS�taryP�rmitNumbe, <br /> The information you provide maybe used by other government agency programs ❑Cherk it rewi_1si7�oon to previous application <br /> (Privacy Laws. 15.04(1)(m)I- State Check <br /> it l D,,NNn to pr <br /> 1. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION X7(0 <br /> Property Owner Name Property Location I <br /> LPG C T W R _SC— 1/4 �1/4,S Z0 T N, R IL; E (or)© <br /> Property 0aill❑g Address Lot Number Block Number <br /> /3o217 pW r <br /> City,State I Lip ode Ph ne Number Subdivision Name or CSM Number <br /> DH rJau i 830 ✓, a <br /> 11. TYPE F B DING: (check one) ❑ State Owned cit' 1ae Nearest Road <br /> 14 Public 1 or 2 Family Dwelling- No. of bedrooms '] TowneOF W 155 5 r} #7 <br /> 111. BUILDING USE: (If building type is public,check all that apply) Parcel Tax Number(s) <br /> 1 ❑ Apartment/Condo -3;)L- <br /> 2 <br /> 3oZ 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. D4 New 2_ ❑ Replacement 3_ ❑ Replacement of q ❑ 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 X 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 3. 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) Elevation <br /> $2 l11% O •s ..3q17- 2- Feet 99.7 Feet <br /> TANK Ca aclt <br /> VII. INFORMATION in gallons Total #of Manufacturer's Name Prefab coo- Fiber- Plastic Exper <br /> New Existin Gallons Tanks Concrete Steel glass App <br /> . <br /> Tanks Tanks strutted <br /> Septic Tank or Holding Tank 1 11 El 11 El El <br /> Lift Pump Tank/Siphon Chamber ❑ El 0 ❑ 1:1 ❑ <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:(N Stamps) MP/MPRSW No.: Business Phone Number <br /> ICHfx�Rn 0v11iAN5 /S'- sa /3 <br /> Plumber's Address(Street,City,State, ip Code): <br /> Z?710 o w 3-5- <br /> IX. <br /> SIX. COUNTY/ DEPARTMENT SE ONLY <br /> El Disapproved Sanitary Permit Fee II"°vda cmondwater E�A <br /> Issuing Agent Sign tur on <br /> proved ❑Owner Given Initial <br /> !!�( na`9e"eI Adverse Determination V <br /> ONDITIONS OF APPROVAL/ REASONS FORDISAPPROVAL: <br /> SHn 6198 L, 05/94) DIARIBUn ON'. Original m(Dont,,one ugry t.: safe,,8 Ruib➢nye Divulon,owner,Plumbxr <br />