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. � <br /> Safety and Buildings Division <br /> r.■ILf1■7 SANITARY PERMIT APPLICATION Bureau of 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 County <br /> than 812 x 11 inches in size. (- <br /> • See reverse side for instructions for completing this application state sanit r Permit Number <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)l. N ...DDG _ � <br /> 1 � <br /> / State Plan LD Number <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION <br /> Pro Ow er ame Property Location <br /> U Q W 1/4/YE1/4,5 3 J T y0 ,N, R /(Q Fol(or)W <br /> Property Owner's Mailing Address 4V Lot Number lock?um' bomber <br /> asp. <br /> City,Sta Zip Code Phone Number Su ivisl Nam o CSM Number <br /> I <br /> (�ir )Y�i'3Y�9 14 a k-, <br /> II. TYPE OFBUILDING: (check one) ❑ State Owned ❑ Cit Nearest[ ad <br /> / 1 1. <br /> Public 1 or 2 Family Dwelling- No. of bedrooE] Village Town of ©a� �1d �.aTK! r,i <br /> 111. BUILDING USE: (If building type is public,check all that apply) Parcel Tax Numbers) <br /> 1F Apartment/Condo .70 — 9o? ,? — U 3516 v <br /> 2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility <br /> 3 ❑ Campground 7 ❑ Merchandise: Sales/Repairs 11 ❑ Restau ant/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 E <br /> -------------------- Tank------------------------Only---------------Existing Syst m-------- -----------Existing System <br /> ------------ <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 RLSeepage Bed 21 ❑Mound 30❑Specify Type 41 ❑Holding Tank <br /> 12❑Seepage Trench 22 Q 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.Area3. Absorp.Area 4. Loading Rate 5. Perc. Rate 6. System Elev. 17. Final Grade <br /> /� Regyired(sq. ft.) Pro osed(sq. ft.) (Gals/d /sq. ft.) (Min./inch) p Elevation <br /> T Ipci, y h s .� /U� Feet fU3'J'Feet <br /> Capacity <br /> VII. TANK ingallons Total #of Prefab Si a Fiber- Expe <br /> INFORMATION g Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App <br /> New Exist: strutted <br /> Tanks Tanks <br /> Septic Tank or Holding Tank ID VV ,t0 "1 El ❑ ❑ ❑ El- <br /> [ift <br /> tlft Pump Tank/Siphon Chamber - ❑ 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 Na}^e:(Pant) // Flu tier's Si atur .(No Sta OAP/MPRSW No: Business Phone Number- <br /> 10.0 T .� e,k ra., 33 74-- 4/7a -0773. <br /> Plumber' d ress(Street,City,State,Zip Code): <br /> VLA �- <br /> IX. COUNTY/ DEPARTMENT USE ONLY <br /> E]Disapproved Sanitary Permit Fee On ludeu Groundwater ate zsue suin Sig na ur ( tamps) <br /> (Approved ❑Owner Given Initial Surcgefee) <br /> a a l r OCX�r <br /> Adverse Determination w h <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> Wil1,398(li.85/99) DISTRIBUTION'. Original ')COLIW y.One<PPY To. s.Aety&Buildings DiviJon,owner,Plumbs <br />