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E <br /> Safety and Buildl�wn <br /> iFn SANITARY PERMIT APPLICATION Bureau of Building Water System <br /> 201 E.Washington Ave. <br /> In accord with ILHR 83 05,Wls.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 ' <br /> than 8 112 x 11 inches in size. <br /> • See reverse side for instructions for completing this application State Sanitary�it No her <br /> /10 <br /> The information you provide maybe used by other government agency programs Check i7revislun to prevCi/D}us application <br /> (Privacy law,s. 15.04(1)(m)L State Plan I y� er <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION <br /> Property Owner Name / Property Location <br /> 2on1At^ e r/r-A--S 1/4 114,S �21 T 3g ,N, RE(ore <br /> Property Owner's Mailing Address r�c r Block Number <br /> _0,2, <br /> 0,2, -;7�� 1 Go✓10712 <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> /� �5`S'7 (f )689 X71 <br /> II. TYPE OF BUILDING: (check one) ❑ State Owned ❑ CitNearest Roacd "� <br /> ge <br /> E] Public 1 or 2 FamilyDwelling- No. of bedrooms --2— Ji Town 01` r / <br /> III. BUILDING USE: (If building type is public,check all that apply) Parcel Tax Number(s) <br /> a6 - aha/ -off yoc, <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 B, if applicable) <br /> A) 1_ ❑ New 2. wi 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❑Seepage Trench 22❑In-Ground Pressure 42❑Pit Privy <br /> 13❑Seepage Pit 43 ❑Vault Privy <br /> 14 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.) Pro osed (sq. ft.) (Gals/day/sq. ft.) (Min/inch q Elevation <br /> 306 3 .S_ 1 1 Feet 7.1 Feet <br /> TANK Capacit <br /> VII• INFORMATION in allons Total #of Manufacturer's Name Prefab con- Fiber- <br /> ass Plastic xPer <br /> New Existin Gallons Tanks concrete strutted steel <br /> Tanks Tanks <br /> Septic Tank or Holding Tank 75-07S' ElF] 1:1 1:1 1:1 <br /> lift Pump Tank/Siphon Chamber G� /'d0 ❑ ❑ ❑ ❑ ❑ ❑ <br /> Vill. 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) MP/MPRSW No.: Business Phone Number: <br /> Plumber's Address(Street,City,State,Zip Code): <br /> -20ow-,.6Zo.Y S/ iii e-- ti <br /> IX. COUNTY/ DEPARTMENT USE ONLY <br /> ❑Disapproved Sanitary Permit Fee (mcmdes Groundwater atelsue Issuing Agen ignature( amps) <br /> Approved ❑Owner Given Initial J�j urcnargefee) / tM 11 <br /> i' _ Adverse Determination ( V (p L <br /> X. CONDITIONS OF APPROVAL/ REASONS FOR DISAPPROVAL: <br /> S111)fi398(H-OVU,n DISIAIBUTION_ Original to Cnuni y,One copy Ta: S.,tety B aulbllny, Own ,,Plumbar <br />