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crnv, <br /> Safety and Buildings Division <br /> Jnr„ 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 8trz x 11 inches in size. B1 r Yig-4 c�26�6 — <br /> • See reverse side for instructions for completing this application State Sanitary Permit_Num er <br /> The information you provide may be used by other government agency programs ❑Check it revision to previous application <br /> I Privacy Law,s. 15.04(1)(m)I. <br /> State Plan I.D.Number <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION <br /> Prop�g rty Owner Nam Property Location <br /> 6eeK e-Nd C 1/4 E 1/4,S T � N, R / W <br /> Property O ner's Mailing Address Lot Number Block Number <br /> coR 'F15 I <br /> City,StateZip Code Phone Number Subdivision Name or CSM Number <br /> 13 Vv all ( > - V �� <br /> . TYPE OF BUILDING: (check one) ❑ State Owned ❑ City Nearest Road <br /> VilE] Public 1 or 2 FamilyDwelling- No. of bedrooms � El Sa Town OF S iSS 15ka-W <br /> , <br /> III. BUILDING USE: (if buildmgtypeispublk,checkallthatapply) Parcel TaxNumber(s) <br /> 1 ❑ Apartment/Condo 0,39— _-54�L7 0 <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 D4 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 /> Required (sq.ft-) Proposed(sq. ft.) (Gals/day/sq.ftJ (Min./inch) Elevation <br /> 00 Z Z , `i. , .6 Feet7 Feet <br /> Capacity <br /> VII. TANK in g llon Total #of Prefab Site Fiber- Exper. <br /> INFORMATION Gallons Tanks Manufacturer's Name Concrete Con- Steel lass Plastic Ap <br /> New Existin strutted g PP' <br /> Tanks Tanks <br /> Septic Tank o)Holding Tank ® 1:1 El El n <br /> Lift Pump Tank/Siphon Chamber 1:1 ❑ ❑ <br /> VIII. RESPONSIBILITY STATEMENT <br /> I,the undersigned, assume responsibil ty for installation of the onsite sewage system shown on the attached plans. <br /> Plumber's Name(Pr t) Plu bei sgnatu e: o Stamps) MP/MPRSW No.: Business Phone Number: <br /> (/S asS�a 6- F <br /> umber's Address(Street!,City,State Zip Code). <br /> 7 d <br /> IX. COUNTY/ DEPARTMENT USE ONLY <br /> (Includes Groundwater ate ue issuing A en I n ufe <br /> Disapproved Sanitary P rmmee 9 g ( tamps) <br /> urcharg,ree) <br /> proved [-]Owner Given Initial 1 1-Cr �2� <br /> l% Adverse Determination l .l Z' <br /> X. CONDITIONS OF APPROVAL/ REASONS FOR DISAPPROVAL: <br /> SBO6398(R.OS194) DISTRIBUTION: Original to County,One toPy To: S,dety&Buildings Divi ion,Owner,Plumtw <br />