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Oy�a''w, <br /> n Safety and Buildings Division <br /> ^,p�■.p; SANITARY PERMIT APPLICATION BUT <br /> of But <br /> Water System. <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 <br /> than 8 112 x 11 inches in size. 7 & h <br /> • See reverse side for instructions for completing this application State Sanitary PjeerymC(l�iJ NN/umber <br /> The information you provide may be used by other government agency programs E] ku vChec2"/o o previo2us application <br /> [Privacy Law,s. 15.04(1)(m)). State Plan I.D.N ber <br /> I. APPLICATION INFORMATION -PLEASE PRINT ALL INFORMATION //Ql__ <br /> Prop e,y Owner Name Property Location <br /> v/ E' i 1 1/a 1/4,5 7 Tgo •N, R/y E(or)/ ' <br /> Propert Owner's Mailing Address Lot Number Block Number <br /> o3" I: ager—,� L4t,le ,u) bd� 1 - /Y <br /> Cit ,Stat[� 4� X� Zip Code Pho a Number Subdivision Name or CSM Number <br /> lch yOIEY V;Ljrest uc+c� o J a yr I�st <br /> 11. TYPE Of BUILDING: (check one) ❑ State Owned ❑ it earest Road <br /> ❑ Vila e <br /> Public 1 or 2 FamilyDwelling- No.of bedrooms -3—, Town OF sCo jam,rcV;4 L weAJ <br /> III. BUILDINGUSE: (If building type is public,check all that apply) Parcel Tax Nu b_e s) <br /> 1 ❑ Apartment/Condo v--#y D&C-4 -O - Zkcv --0/-J/4V0 <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, ❑ 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§�'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 /> Sv Required (sq.ft.) Proposed(sq.ft.) (Gals/day /sq.ft.) (Min./inch) ! Elevation <br /> y,4 g 3 G� Feet 96.00 Feet <br /> VII. TANK Capacity site <br /> in gallons Total #of Manufacturer's Name Prefab. Con- Steel Fiber- plastic Exper <br /> f <br /> INFORMATION New Existin Gallons Tanks Concrete strutted glass App. <br /> Tanks Tanks <br /> Septic Tank or Holding Tank IDOL) /00 L7 W/eJ B j C/ <br /> crr fe a 1:1 ❑ 1—:1 _0 ❑ <br /> Lift Pump Tank/Siphon Chamber I I Q El ❑ ❑ El <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) <br /> lans.Plumber'sName:(Print) Plumber's Signature:(No Stamps) MP/MPRSWNo.: Business Phone Number: <br /> Plumber'sAddre (Street,Cit ,State,ZipCode): 4.1 <br /> IX. COUNTY/ DEPARTMENT USE ONLY <br /> ❑Disapproved Sanitary Permit Fe (includes Groundwater ate s ue Issuing Ag tSig to N Stamps) <br /> Surcharge Fee) <br /> Approved ❑Owner Given Initial <br /> Adverse Determination / <br /> X. CONDITIONS OF APPROVAL/REASONS FUR—DISAPPROVAL: <br /> SBD-6398(R.05/94) DISTRIBUTION: Original to County,one copy To: Safety&Buildings Division,Owner,Plumber <br />