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On nTyyVr <br /> Safety and Buildings Division <br /> vi7��1n SANITARY PERMIT APPLICATION Bureau of Building 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 County <br /> than 8 1/2 x 11 inches in size. N, `'— <br /> • See reverse side for instructions for completing this application State,Sanrtz ry Fill Number <br /> (moi t 2 c�`1Sol G <br /> The information you provide maybe used by other government agency programs ❑Ch ck II r vlsl n to previous application <br /> Privacy Law,s. 15.04(1)(m)l. <br /> State Plan I.D.Number <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION S^ <br /> Prop yOwner NamProperty Location <br /> 'DINamejgHe 4,S T N, R E(orG� <br /> Property OQw ear's Mailing Address Lot Number Block Number <br /> 7L3 O uc LtI <br /> Cit ,State Z C de Phone Number <br /> ErC 1x11 - 3 )b3S 3 <br /> II. TYPE OF BUILDING: (check one) E] State OwnedElity Nearest Road <br /> ❑ Village <br /> E] Public 1or2Famil Dwelling-No. ofbedrooms 3 own OF S'CD <br /> III. BUILDING USE: (If building type is public,check all that apply) Parcel Tax Nuumber(s)1 3M1 F-1 Apartment/Condo - - 1 l� <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. Y Replacement 3. ❑ Replacement of q ❑ Reconnection of 5 ❑ Repair of an <br /> System T-'System Tank Only Existing Sysl em 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 /> 1 1 ❑Seepage Bed 21 UMound 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 PerDay 2. Absorp.Area 3. Absorp.Area 4. Loading Rate 5. Perc. Rate System Elev. 7. Final Grade <br /> Required q- ft.) Proposed(sq. ft.) (Gals/day/sq.sq. ft.) (Min./in h) 103. <br /> 3 Feet Elevation <br /> REPIf as. &p57Feet <br /> Ca aut <br /> VII. TANK in gallons Total #of Prefab 1Ye Finer- Expe <br /> INFORMATION Gallons Tanks Manufacturer's Name concrete ()n- Steel Plastic p <br /> New Existin str cted glass App. <br /> Tanks Tanks <br /> Septic Tank or Holding Tank — 2-50 ❑ El ❑ <br /> Lift Pump Tank/Siphon Chamber, loon "-- ❑ Ei Ei Ei <br /> VIII. RESPONSIBILITY STATEMENT <br /> I,the undersigned,assume responsibility for installation of the onsite sewage system shown i In the attached plans. <br /> Plumber's Name:(Print) Plumber's Signature:(No mps) MP/MPRSW No.. Business Phone Numb r: <br /> c+1 oPKi�/s L!'j C44f ZG 6- 66- /57 <br /> PI m ber's Add ress(St reet,CiState,Zl Code): <br /> _Z_-776� w .3s <br /> IX. COUNTY/ DEPARTMENT USE ONLY <br /> E]Disapproved Sanitary Permit Fee 0 ,IudesOmundw1le1 Date Issue Issw gAg tSig nat r (N Stamps) <br /> Approved ❑Owner Given Initial <br /> Adverse Determination �t O � 10 A-ci <br /> X. CONDITIONS OF APPROVAL/ REASONS FOR DISAPPROVAL: <br /> SBO.E391t(R.OS/94) DI SIRIBUTION'. Original m(numy,One mpy To: S�feIyBBUIIAiny D'rvmmn,Owner,Plum r <br />