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. � <br /> ttA� `vo...olPf BureauoSafety fnd Building Water WaterSystem-.Division <br /> ■� �, SANITARY PERMIT APPLICATION 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 8 112 x 11 inches in size. &94Mo�ga� <br /> • See reverse side for instructions for completing this application State Sanitary Perm l Number <br /> 3oo � 9h <br /> The information you provide may be used by other government agency programs ❑Check it revision to previous application <br /> [Privacy Law,s. 15.04(1)(m)]. <br /> State Plan I.D.Number <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION <br /> Property Owner Name Property Location <br /> 1/4 1/4,S 3q_ T N, R lb E(or)s <br /> Prop e yOwner's Mailing Address Lot Number Block Number <br /> [oS 1 1 3 <br /> City,State Zip Code Ph ne Number Subdivision Name or CSM Number <br /> f WI 22 ( >I425 -Wo 1ES ES S <br /> II. TYPE F BUILDING: (check one) ❑ State Owned El City Nearest Road <br /> Public 1 or 2 FamilyDwelling-No.of bedrooms Z E rowan OF 01q Kuqgn SEFFRIES RD , <br /> III. BUILDING USE: (If building type is public,check all that apply) Parcel TaxNumber(s) <br /> 1 ❑ Apartment/Condo 020 Or-2_25 O3 900 <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. g 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 [A 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 Per2. 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) Elevation <br /> 3Day 00 Z 2- q(0.3 Feet 106.0 Feet <br /> TANK Capaclt <br /> VII INFORMATION in allons Total #of Manufacturer's Name Prefab. Site Con- steel Fiber- Exper <br /> New Existin Gallons Tanks Concrete glass Plastic App <br /> strutted <br /> Tanks Tanks <br /> Septic Tank or Holding Tank ' ❑ ❑ ❑ ❑ ❑ <br /> Lift Pump Tank/Siphon Chamber ❑ ❑ ❑ ❑ ❑ ❑ <br /> VI11. 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: Stamps) MP/MPRSW No.: Business Phone Number: <br /> Ic A02 0 KI 5 ''.�`fua 715- Sul- g151 <br /> lumber's Address(Street,City,State,Zip Code): <br /> Z'11 to O w 35 EBS`rE2 W I. $ 3 <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑Disapproved Sanitary Permit Fee (includes Groundwater Date Issued lissuing Agent Sign re(N tam <br /> Approved ❑Owner Given Initial f�5dargefee) 9�Z��7 <br /> Adverse Determination <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(R.05/94) DISTRIBUTION: Original to County.One copy To: Safety&Buildings Division,Owner,Plumber <br />