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Safeand Buil vision <br /> MtsL`ir�; SANITARY PERMIT APPLICATION Bureau BuildingWaterSystem <br /> 201 E.Washington Ave. <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 / <br /> than 8 1/2 x 11 inches in size. E �/6 <br /> • See reverse side for instructions for completing this application ate Sa `ttar <br /> J' Plrrp N q <br /> The information you provide maybe used by other government agency programs ❑Check it revision to previous application <br /> [Privacy Law,s. 1 5.04(1)(m)]. State Plan I.D.Number / <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION ' <br /> Propert Owner Name Property Location _ <br /> u S0t/4 4,S Iq T ,N, R E(or(w) <br /> Prope yOwner's Maili gAddress Lot Number Block Number <br /> 2174 .5LAKy DliZ <br /> City,State I Zip Code Phone Number SubdivisionName or CSM Number <br /> 014E SE W1 . z ( )2 <br /> oS 8-3795Alcgigs <br /> II. TYPE OF BU DING: (check one) ❑ State Owned ❑ city Nearest Road <br /> ❑ Village t <br /> ❑ Public 1 or 2 FamilyDwelling- No.of bedrooms 7__ Town OF u CD LN b- <br /> HI. BUILDING USE: (If building type is public,check all that apply) P el TaxNumber(s) <br /> 1 ❑ Apartment/Condo bib 3L(t 01 700 02, 0©O <br /> 2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing H e utdoor 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. (Gt New 2- F1 Replacement 3- ❑ Replacement of 4. ❑ Reconnection of 5- ❑ Repair of an <br /> tP 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 p4 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) Q,1 Q Elevation <br /> 300 Zq 3 7- •7 17• I Feet 9 7.q Feet <br /> TANK Ca aut <br /> VII. Site <br /> I FORMATION in gallons Total #of Manufacturer's Name Prefab. Con- Steel Fiber- Plastic Lxper_ <br /> ©New Existin Gallons Tanks Concrete strutted Blass App. <br /> Ta�n�ks Tanks e^ c <br /> Septic Tank or Holding Tank Soo yv0 / JKpW/ 91 ❑ ❑ ❑ ❑ ❑ <br /> Lift 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 amps) MP/MPRSW No.: Business Phone Numbe <br /> 66- 5 <br /> Plumber'sAddress(Str et,City,State Zip Code) U6901159- `t <br /> Z O w -3S <br /> IX. COUNTY/ DEPARTMENT USE ONLY <br /> ❑Disapproved Sanitary Permit Fee (Intludes Grovndwater ate slue Issu ng Agent S natu (N to s) <br /> Surcharge hee) <br /> Arl proved [-]Owner Given Initial <br /> Adverse Determination / <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(R.05/94) DISTRIBUTION: Original to CourJy.One ropy To: Safety&Ruildings Divivon,Owner,Plumber <br />