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^ " ^ Safety and Buildings Division <br /> "■a.r... SANITARY PERMIT APPLIC TION Bureau of Building Water Systems <br /> 201 E.Washington Ave. <br /> In accord with ILHR 83.05,Wis.Adm.Co e 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 _ /�7[0 d <br /> than 8112 x 11 inches in size. ; y,,� 7 7 (Q <br /> • See reverse side for instructions for completing this application State Sanitary Permit Number <br /> A,5 D19 <br /> The information you provide maybe used by other government agency programs ❑Check d reviswn to previous application <br /> [Privacy Law,s. 15.04(t)(m)I- State Plan I .Number <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION <br /> Property Owner Name 1 Prop Location < <br /> iUE /a 5,�- 1/4,5 / b T 3 9 ,N, R E(or) 11/� <br /> Property Owner's Mailing Address Lot Numer Block Number <br /> 7,v 60 11 y a r_/ V 1' `— — <br /> City,State Zip Code Phone Number Subdonsi n Name or CSM Number <br /> II, TYPE OF BUILDING: (check one) ❑ State Owned [3 Cit Nearest Road / <br /> E] Public 1 or 2 FamilyDwelling- No. of bedrooms Town DF 44'j,15 -tee. e, osj �^f <br /> III. BUILDING USE: (If building type is public,check all that apply) Parcel Ta Nuumber(s) �7 <br /> 1 ❑ Apartment/Condo <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 It,if applicable) <br /> A) 1. 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 [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 Rae 5. Perc. Rate 6. System Elev. 7. Final Grade <br /> _ Required (sq. ft.) Proposed (sq. ft.) (Gals/day/sq. .) (Min./inch) Elevation <br /> y� Y la Y S% - 6 — �5 a Feet q7 Feet <br /> VII. TANK Ca ut <br /> o <br /> Site <br /> INFORMATION n gallons Total #of Manufacturers Name Prefab Con- Fiber- Plastic Exper <br /> New Existin Gallons Tanks Concrete Steel glass App. <br /> Tanks Tanks stru ted <br /> Septic Tank or Holding Tankd dt) -SD�'j¢t:� 0 El El El El ElDpC% <br /> L ift 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:(Print) Plumber's Signature.(No Stamps) / M /MPRSW No.: Business Phone Number: <br /> Plumber's Address(Street,City,State,Zip Code): <br /> „CS C) X s ev Sir e>-u G--'-Ir- -:5 y 97•� <br /> IX. COUNTY/ DEPARTMENT USE ONLY <br /> ❑Disapproved Sanitary Permit Fge timmaescrol,r,d.,iW ate is Ice Issuing Agent Signatur N amps) <br /> Approved [-IOwner Given Initial �(/�Suanarge roe) <br /> Adverse Determination Q�Q � <� <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> %HD-6398(R.BS/94) DISTRIBUTION: Originalm Cnunly,Une<opy To: SalelyB ulldinge Dimuun,0wner.DlumBer <br />