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�-�.ecrrw>h <br /> Safety and Buildings Division <br /> -` ..77ec. Q SANITARY PERMIT APPLICATION 201 W.Washington Avenue <br /> •` eons,n in accord with ILHR 83.05,WiS.Adm-Code P 0 Box 7302 <br /> Department of Commerce Madison,WI 53707-7302 <br /> • Attach complete plans(to the county copy only)for the system,on paper not less County <br /> than 81/2 x 11 inches in size. Q/�Dl2�t.�7 K.� <br /> • See reverse side for instructions for completing this application state sanitary Permit Number JJ <br /> i��9,5 <br /> Personal information you provide may be used for secondary purposes ❑Ch ec if vision to previous application <br /> tPrivacy Law,s. 15.04(1)(m)]. State Plan I.D.Number , <br /> 1- APPUCATION INFORMATION- PLEASE PRINT ALL INF RMATI N I ��--- <br /> Property Owner Name Property Location <br /> SLE f �.( — ��— ,SWI14 5W 1/4,S 7// <br /> T LIV •N•R /5"E(orjC <br /> Property Owner's Mailing Address Lot Number1510Block Number <br /> W 78 lUe- 4{QGrl&_ i� <br /> City.Sta Zip Code Phone Number Subdivision Name or CSMA?uje <br /> l5D 6,iN p S D64E- e 55L12Z ( 7/S) 535- 199 � o e acv S4 <br /> IFTVFM BUILDING: (check one) ❑ State Owned ❑ ity Nearest Road <br /> Public 1 or 2 FamilyDwelling-No.of bedrooms b own of +�aZ- '; A11 S�ar/� MwN T� q), <br /> III. BUILDING USE: (If building type is public,check all that apply) Parcel TaxNumber(s) q ` <br /> 1 ❑ Apartment/Condo 6 /,a <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. tdNew 2. ❑ Replacement 3_ ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an <br /> ----__ystem System _ Tank Only---------------Existing System----------ExistingSystem <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 /> 11Seepage Bed 21 ❑Mound 30 L]Specify Type 41 E]Holding Tank <br /> 12❑ eepage 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 /> Required(sq.ft.) Proposed(sq.ft.) (Gais/day/sq.I (Min./inch) , Elevation <br /> 3©© <br /> �� T -3 c;,> '7Z'9/"Feet 75520 Feet <br /> TANK Capacity VII. INFORMATION in gallons Total lis Tanks Manufacturer's Name Concrete Con- Steel glass site Fiber- Plastic Aper. <br /> New lExisting strutted <br /> Tanks Tanks <br /> Septic Tank or Holding Tank 7 J� W CL Cp l ❑ ❑ El ❑ ❑ <br /> Lift Pump Tank/Siphon Chamber ❑ El El 11 ❑ El <br /> VIIL RESPONSIBILITY STATEMENT <br /> I,the undersigned,assume responsibility for installation of the onsite sewage system shown on the attached plans. <br /> PI tier's Name:(Print) Plu s natur ( ) MP/MPRSW No.: Business Phone Number: <br /> z 221o67D ?! 5' z� 3 —V <br /> Plumber's Address(Street,City,State, <br /> 79Code): <br /> ): <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑Disapproved Sanitary Permit Fee lindudesGroundwater ate Issued Issuing en ign ture N tamps) <br /> A roved17,5 '4' <br /> Sur fiarge ree) <br /> pp ❑Owner Given Initial 7 <br /> Adverse Determination / / � <br /> X. CONDITIONS CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> DISTRIBUTION: Original to County.One copy To: Safety 8 Buildings Division,Owner,:Plumber <br />