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afety <br /> SANITARY PERMIT APPLICATION lA 'Berea of Building ateriSy <br /> \�___111 Bureau of Building Water System <br /> In accord with ILHR 8305,Wis.Adm CodeY\n 201 E.Washington Ave.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 unt <br /> than 8 12 x 11 inches in size- ( �el 1� <br /> • See reverse side for instructions for completing this application <br /> LMN <br /> Sta nit�re� Nu erThe information youprovide may be used by other government agency programs ((J�Privacy Law,s. 15.04(1)(m)J. Check it revision to previous application <br /> State Plan 1.13 NumberI. APPLICATION INFO ATION - PLEASE PRINT ALL INFProperty Owner Name U W ,�, cation <br /> LPrope-rty <br /> 2 1/a,S 3S� T. N, RE(ors Mail Address Block Number <br /> a Zip Code Phonh Number Subdivision-1Name or umber <br /> 6;40e C�✓ SQ3 ( ) a .;2 <br /> II. T OF BUILDING: (check one) E] State Owned °pvila a Nearest Road <br /> Public 1 or 2 Family Dwelling- No. of bedrooms Town OF /!?t� .v <br /> uc. <br /> 1 o%4iv rC/ <br /> 111. BUILDING USE: (If budding type is public,check all that apply) Parcel TaxNumber(s) <br /> 1F Apartment/Condo / Y— 3 3 :3 5r_ © 7 2 3 0 <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 <br /> 5 Hotel/Motel 12 ❑ Service Station/Car Wash <br /> ❑ 9 ❑ Office/Factory 13 ❑ Other: specify <br /> IV. TYPE OF PERMIT: (Check only one box on line A. Check box online B, if applicable) <br /> A) 1. ;K New 2. ❑ Replacement 3. Replacement of Reconnection of <br /> System ❑ 5. Existing <br /> p an <br /> _______y _ _-_-System - -- - Tank Only -- - Existing Svstem------ ❑_ 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 /> 1 1 XSeepage 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 /> SO Required(sq. ft.) Proposed(sq.ft.) (Gals///sq.ft.) (Min./inch) Elevation <br /> 9OQ 90Q , S Feet Feet <br /> VII. TANK Capacity <br /> INFORMATION in gallons Total #of Prefab Site er <br /> Fiber- Ex <br /> New Existing Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic APp <br /> Tanks Tanks strutted <br /> Septic Tank or Holding Tank QQQ 00 p ❑ ❑ ❑ ❑ ❑ <br /> Lift Pump Tank/Siphon Chamber 00 L ❑ ❑ <br /> VIII. RESPONSIBILITY STATEMENT yj <br /> I,the undersigned,assume responsibility for installation of the onsite sewage system shown on the attached plans- <br /> Plumber's <br /> Name:(PTin Plumber'sSignatur (No Stam s) MP/MPRSWNo.: Business Phone Number: <br /> �z/ .��o/„-, may(/.� ✓.� � � �S/9r— �?8� <br /> Plumber's Address(Street,Ci>y,State,Zip Code): <br /> � � sly s.��..� G✓.�` sys��� <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> E]DisapprovedSanitary Permit Fee (Includes Groundwater ate I su Issuing Agent ignat re(N S ps) <br /> Approved ❑Owner Given Initial ) Surchargeree) <br /> Adverse Determination <br /> X. CONDITIONS OF APPROVAL I REASONS FOR DISAPPROVAL: <br /> ,BD-6398(R.05/94) DISTRIBUTION. Original 10 County.One copy To: Safety&Buildings Diw.ion,Owner,Pluintrer <br />