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Safety and Buildings Division <br /> rniiPeiinBureau of Building Water System. <br /> �■a.r■r■ SANITARY PERMIT APPLICATION 201E-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. S U rn7 <br /> • See reverse side for instructions for completing this application State Sanitary PermitNu*m/ber <br /> The information you provide may be used by other government agency programs L]Check it r2yo�viousaa�icarion <br /> [Privacy Law,s. 15.04(1)(m)l. State Plan I _Number <br /> 15-)C/6` <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION <br /> Property Owner Name Property Location <br /> P_ -5 - ) "-/Sc3 /LJi 114 1/4,S�Fq TJ 7 ,N, R �� E (or)(@ <br /> Prope y Owner's Mailing Addre s Lot Number Block Number <br /> � o q/ s - - r d#,1-) <br /> City,StateI Zip Code Phone Number Subdivision Name or CSM Number <br /> II. TYPE OF BUILDING: (check one) ❑ State Owned ❑ ate Nearest Road n� <br /> E] Public 1 or 2 FamilyDwelling- No. of bedrooms . 2 CW Town of JOL <br /> 111. BUILDING USE: (If buildingtype is public,check all that apply) Parcel Tax Number(s) <br /> 1 ❑ Apartment/Condo 9y /'0-75" 2 700 <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 /> S ❑ 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. KReplacement 3. ❑ Replacementof 4. ❑ Reconnectionof S_ ❑ Repair of an <br /> System System Tank Only Existing System Existing System <br /> ------ ---------------- -------------- <br /> B) ❑ A Sanitary Permit was previously issued. Permit Number Date Issued <br /> V. TYPE OF SYSTEM: (Check only one) <br /> NonPressurizedDistribution Pressurized Distribution Experimental Other <br /> 11 ❑Seepage Bed 21 ❑Mound 30❑Specify Type 41 X 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 S. Perc. Rate 6. System Elev. 7. Final Grade <br /> Required (sq. ft.) Proposed(sq. ft.) (Gals/day/sq. ft.) (Min/inch) Elevation <br /> C) — Feet Feet <br /> TANK Capacity <br /> VII. INFORMATION in gallons Total #of Manufacturer's Name Prefab eon Steel Fiber- Exper <br /> Gallons Tanks concrete glass Plastic App <br /> New Existin strutted <br /> Tanks Tanks <br /> Senrir Tank or Holding Tank app v?I10 c1 S//S/5c�� ILY ❑ ❑ ❑ ❑ ❑ <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: Stamps) MP/MPRSWNoo: Business Phone Number: <br /> � // <br /> Plumber's Address(Street,City,State,Zip Code): <br /> IX. COUNTY/ DEPARTMENT USE ONLY <br /> E]Disapproved Sanit ermi ee awater ate ue Issuing a SignMeps) <br /> Approved ❑Owner Given Initial geleel yJ / lr <br /> Adverse Determination LTJ l <br /> X. CONDITIONS OF APPROVAL/REA S FO 1 APPROVAL: <br /> WD 4,398 In 0194) DISTRIBUTION. Original,n(nuoy,One«pY To: S.,lety&RuilJinga Dimilon,nwner,Plumh.xr <br />