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Safe�dBuildings ivision <br /> SANITARY PERMIT APPLICATION Bureau of Building Water System <br /> 201 E Washington Ave- <br /> r• 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 8 112 x 11 inches in size. r /-/u r <br /> State t�Permit umber <br /> • See reverse side for instructions for completing this application //'J r:�L <br /> The information you provide may be used by other government agency programs ❑ <br /> Check d revision t previous application <br /> [Privacy Law,s. 15.04(1)(m)I. State Plan I_D.Number- i _ <br /> I. APPLICATION INFORMATION- PLEASE PRINT ALL INFO RMATpIION ration //'/,�^1� <br /> Property Owner Name ,�Property <br /> 1/4,$ TT�/ ,N, R/�E(or <br /> � ,'J�- Block Number <br /> Lot Number / <br /> Property Owner's Mailing Address {/�� <br /> City,State Z� ode Phone Number Subdivision Name or CSM Number <br /> )y8s-9� c3,� 9 7 <br /> ❑ City Nearest Rea <br /> II. TY E F BUILDING: (check one) ❑ State Owned 0 Village <br /> ❑ Public 1 or 2 FamilyDwellin No.of bedrooms Town OF UJ <br /> Parcel Tax Number(s) <br /> !II. BUILDING USE: (If building type is public,check all that apply) _:-. . - '�f'Ul <br /> 1 ❑ Apartment/Condo <br /> Medical Facilit /Nursin Home 10 ❑ Outdoor Recreational Facility <br /> 2 ❑ Assembly Hall 6 ❑ y g 11 ❑ Restaurant/Bar/Dining <br /> 3 EDCampground 7 ❑ Merchandise:Sales/Repairs 12 Service Station/Car Wash <br /> 4 ❑ Church/School 8 F1 Mobile Home Park ED <br /> 13 ED Other: specify5 EDHotel/Motel 9 EDoffice/Factory <br /> FNon-Pressurized <br /> OF PERMIT: (Check only one box on line A. Check box on line B,if applicable) Repair of an <br /> New 2. ❑ Replacement 3. ❑ Replacement of _ 4_ ❑ Reconnection of 5. ❑ P . <br /> Tank OnlyExisting System -- ___Existing System <br /> System --------System -------------------- -------------- <br /> ❑ A Sanitary Permit was previously issued. Permit Number <br /> Date Issued <br /> OF SYSTEM: (Check only one) <br /> ssurized Distribution Pressurized Distribution Experimental <br /> Other <br /> 21 Mound 30❑Specify Type 41 ❑Holding Tank <br /> page Bed ❑ 42❑Pit Privy <br /> epage Trench 22❑In-Ground Pressure 43❑Vault Privy <br /> epage Pitstem-In-Fill <br /> VI. ABSORPTION SYSTEM INFORMATION: -i rnnni <br /> 1. Gallons Per Day 2. Absorp.Area 3. Absorp.Area 4. Loading Rate S. Perc. Rate 6. System Elev. Elevation rade <br /> Required (sq.ft.) Proposed (sq.ft.) (Gals/day/sq.ft.) (Min./inch) <br /> S/_5-0 6 % 6 Y y.71:5-, Feet";5— Feet 97�9 <br /> VII. TANK Capacity Total #of Prefab Site Fiber- Plastic Exper <br /> in gallons Manufacturer's Name Concrete Con- Steel glass App. <br /> INFORMATION New Existin Gallons Tanks structed <br /> Tanks Tanks <br /> Septic Tank or Holding Tank �e�c� OAt� ❑ ❑ Cl <br /> El El El <br /> Lift Pump Tank/Siphon Chamber <br /> VIII. RESPONSIBILITY STATEMENT <br /> I,the undersigned,assume responsibility for installation of the onsite sewage system shown on the attached plans. <br /> MP/MPRSW No.: Business Phone Number: <br /> Plu/m'ber's Na/me:(Print) Plumber's Signa/tura Stamps) <br /> L'� :-/ �.- /1 4�} !' Ci/ I�`I ��c�-rh.y, l/`� -�ar. ci✓�Cs / t� y 7 �� �'� <br /> Plumber's Address(Street,City,State,Zip Code): _T 5f <br /> 1.71 <br /> IX. COUNTY/ DEPARTMENT USE ONLY <br /> Disapproved SanitaryPermit Sw,desG(oundwater atelss IssuingAgen i ature o5 <br /> EDpp Surcharye fee) <br /> Approved E]Owner Given Initial <br /> Adverse Determination <br /> X. CONDITIONS OF APPROVAL/ REASONS F DISAPPROVAL: <br /> SHO-6398(H.05/94) <br /> DISTRIBUTION'. original to enW,iy,one Ulpy To: Safety&Ruilding6 nivision,owner,Plumtrar <br />