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Cil c� <br /> DIM <br /> SafetyandBuildmg Division <br /> SANITARY PERMIT APPLICATION Bureau a Building Water Systems <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 Count r <br /> than 8 12 x 11 inches in size. <br /> • See reverse side for instructions for completing this application State Sanitary Permit Number <br /> (U�q <br /> The information you provide may be used by other government agency programs E]Check it revisio��iau <br /> vs 6.6. <br /> [Privacy Law,s. 15.04(1)(m)). State Plan I.D.Number <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION <br /> Pr �eOwNa` <br /> �. ropert location <br /> prtner Q >/I 2Y.h1 r� 1/ate t/a,S 1, T N, R ..F..{Ar W <br /> Propert Owner's Mailing Addres Lot Number Block Number <br /> 2l — 1 U � <br /> Ci tate Zip Code Phone Number Subdivision Name or CSM Number <br /> .P.0,0 kC� (.l)iS II q 1( / )(p h_ 3 <br /> Ill. TYPE 0F BUILD[ G: (Check one) ❑ State Owned ❑ it age <br /> Nearest Road <br /> Public 1 or 2 FamilyDwellingEI v2age No. of bedrooms Town OF ► [o� v� 1 <br /> III. BUILDING USE: (If building type is public,check all that apply) Parcel TaxNumber(s) <br /> 1 ❑ Apartment/Condo t) / 3�/ <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 Be if applicable) <br /> A) 1New 2- E] Replacement 3. ❑ Replacement of 4_ E] Reconnection of 5. E] Repair of an <br /> _System __ ____System ____________ TankOnly __________ _ Existing System ________Existing <br /> 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®Seepage Bed 21 ❑Mound 30❑Specify Type 41 ❑ Holding Tank <br /> 12)qSeepage Trench \it rtl}r``� 22 F1In-GroundPressure 42❑Pit Privy <br /> 13 E]Seepage Pit \ 43❑Vault Privy <br /> 14❑System-In-Fill <br /> VI. ABSORPTION SYSTEM INFORMATION: i <br /> 1. Gallons Per Day 2. Absorp.Area 3. Absorp.Area 4. Loading Rate 5. Perc. Rate 6. System Elev. 7. Final Grade <br /> r—© ReqLr��(sq. ft.) Proposed(sq.ft.) (Gals/day/sq.ft.) (Min./inch) q Elevation <br /> J , 8 ll� Feet 73, 7 Feet <br /> VII. TANK Capacity Site <br /> INFORMATION in gallons Galltons a of <br /> Manufacturer's.Name coneebte Con- Steel glass Plastic APp. <br /> New Existingstrutted <br /> Tanks Tanks Q'' I pQt <br /> eptic Tan r Holding Tank 00 t7 - S KY Q El Q r El <br /> Lift Pump Tank/Siphon Chamber Ej El ❑ ❑ El <br /> VIII. RESPONSIBILITY STATEMENT <br /> I,the undersigned, assume responsibi ity for installation of the onsite sewage system shown on the attached plans. <br /> Plumber's Nam :(Print) Plu ber'sSignatu e:( Stamps) MP/MPRSW No.: Business Phone Number: <br /> 2l S oar 2Z SLZ 7/ <br /> Plum er's Addresseiei(Street„ ity,Stat ,Zip Code,�c� <br /> IX. COUNTY/ DEPARTMENT USE ONLY <br /> ❑Disapproved Sanitary Permit Fee (Incudes Groundwater ate ss a Issuing Agent Sig ture(No Sta p <br /> � roved J / Sade Fee) �� <br /> pp ❑Owner Given Initial /%S .�� <br /> Adverse Determination <br /> X. CONDITIONS OF APPROVAL/ REASONS FORDISAPPROVAL: <br /> �eU6teP 43 J Sid <br /> P. <br /> 5RD-6398(R.05/94) rMTRIBDTIDN. Original to C... One n+Py To: Sudety 8 Ruildings Dive-ion,Owner,lelumtrer <br />