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LX,`f`- r�/0 P Safety and Bu d ng�ivision <br /> Bureau of Building Water Systems <br /> •vrirri SANITARY PERMIT APPLICA ON 201 E.Washington Ave. <br /> P.O.Box 7969 <br /> In accord with ILHR 83.05,Wis.Adm.Code Madison,WI 53707-7969 <br /> • Attach complete plans(to the county copy only)for the system,on paper not less Cou t 4206 <br /> than 8 1/2 x 11 inches In size. State Sanitary Permittuber <br /> N <br /> • See reverse side for instructions for completing this application �a� � 33 <br /> - El Check i revision to previous application <br /> The information you provide maybe used by other government agency programs State Plan I.D-Number, <br /> (Privacy Law,s- 15.04(1)(m)1- �(/ <br /> 1. APPLICATION INFORMATION - PLEASE PRINT ALL INF ORMA peONocation '/ <br /> Property wrier Name s I 1/4 1/4,S o? 7 T ck ,N, ��j E(or <br /> C_ Black Numbee r <br /> Lete <br /> Property OwCl is L, 5' <br /> Mailing Address � / <br /> d t� Z�� G/ Subdivision Name or CSM Number <br /> City,State, Zip Code Phone Number <br /> 6 e d^ Nearest Road <br /> State Owned Cl City <br /> II. TYPE OF BUILDING: (check one) ❑ � ❑ village L K <br /> ❑ Public 1 or 2 Famil Dwelling-No-of bedrooms Parcel Jn OF bek��� <br /> 111. BUILDING USE: (if building type is public,check allthat apply) <br /> p 0 3--2 05 o0 <br /> 1 ❑ Apartment/Condo 10 Outdoor Recreational Facility <br /> 2 ❑ Assembly Hall 6 F-1 Medical Facility/Nursing Home 11 0 Restaurant/Bar/Dining <br /> 3 F1 Campground 7 [1 Merchandise:Sales/Repairs 12 ❑ Service Station/Car Wash <br /> 4 ❑ Church/School 8 ❑ Mobile Home Park 13 ❑ Other: specify <br /> 5 [1Hotel/Motel 9 ❑ Office/Factory <br /> IV. TYPE OF PERMIT: (Check only one box on line A. Check box on line B, if applicable) Re air of an <br /> Rep= <br /> of 4. Reconnection of 5. ❑ ?pair <br /> Re lacement 3. p ❑ -Existing System <br /> A) 1. F-1 New 2. p ❑ TankOnl Existin S stem <br /> System S-stem Y------------------- 9 -y------- <br /> _ _ -y-------------- Date Issued <br /> B) ❑ A Sanitary Permit was previously issued. Permit Number <br /> V. TYPE OF SYSTEM: (Check only one) Experimental Other <br /> Non Pressurized Distribution Pressurized Distribution 30❑ p yyp 5 ecif Type 41 C]Holding Tank <br /> 11 QASeepage Bed <br /> 21 E]Mound 42❑pit Privy <br /> 12❑Seepage Trench 22❑In-Ground Pressure 43❑Vault Privy <br /> 13❑Seepage Pit <br /> 14❑System-In-Fill <br /> VI. ABSORPTION SYSTEM INFORMATION: 7. <br /> 1. Gallons Per Day 2. Absorp.Area 3. Absorp.Area 4. Loading Rate 5. Perc. Rate 6. System Elev. Elevation <br /> rade <br /> on <br /> Required(sq. ft.) Proposed(sq.ft.) (Gals/day/sq.ft.) (M` in-/inch) 93-7 Feet 77,2 Feet <br /> CapaClty Prefab. Site Fiber- plastic Exper. <br /> VII. TANK in gallons Total #of Manufacturer's Name concrete con- steel glass APP <br /> INFORMATION Gallons Tanks structed <br /> New Existin <br /> Tanks TanksEl ❑ ❑ ❑ ❑ <br /> Septic Tank or Holding Tank �drj <br /> o� S�',4 r_1 ❑ ❑ ❑ ❑ ❑ <br /> Lift Pump Tank/Siphon Chamber <br /> VIII. RESPONSIBILITY STATEMENT <br /> 1,the undersigned,assume responsibility for installation of the onsite sew nangRswNo system shown o euh Battached hone Number: <br /> Plumber's Name:(Printt)) Plumber's Signature:(No Stam s) / y� `2-2 k� <br /> Plumber's Address(Street,city,state,LIP ev <br /> IX. COUNTY/ DEPARTMENT USE ONLY a <br /> E]Disapproved Surcharg ) <br /> Sanita ry Permit F2Q (Includes Groundwater ate ISSUIngA nt IgnatUr e ree) <br /> oved F1 owner Given Initial / Z <br /> Adverse Determination <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> DIS i'NIBUTI[1N: <br /> PlumGer <br /> Original to Cot <br /> y,One mPy To: Satety 8 BuilJings Division,Owner, <br /> SBD 639H(It.051941 <br />