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Safety and Buildings Division <br /> �-� Bureau of Building Water Systems <br /> SANITARY PERMIT APPLICATION <br /> V��II.AIA 20, E.Washington Ave. <br /> In accord with ILHR B3 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 12 x 11 inches in size. State Sanitary Permit Number <br /> • See reverse side for instructions for completing this application '360-2�/3 <br /> The information you provide may be used by other government agency programs ❑Check if revision to previous application <br /> (Privacy Law,S. 15.04(1)(m)]. State Plan I.D.Number <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION <br /> Property Owner Name 1� Property Locavon �N, R (L E(Or)(9 <br /> 5-1 rrt d'Y1l , 4 ,/4,s 34 T <br /> Property Owner's Mailin Address A Lot Number Block Number <br /> 7Ib4 ANIt-f.r tt�fE 5+�= 2 <br /> City,State Zip Code Phone Number Subdl (Sion Name qT�CSM Number o 3e� <br /> n I (b51 )7(0 - oCCG".�7. 1't.fi7 <br /> 0 Icy Nearest Road <br /> II. TYPE F BUILDING: (check one) ❑ State Owned p Village <br /> Public 19 1 or 2 Family Dwelling-Noof bedrooms A3— 6cTown OF MeendrAl1'E�ht� <br /> 111. BUILDING USE: (If building type is public,checkallthatapply) <br /> Parcel Tax Number(s) <br /> ol$-4fa50 o7--zoo <br /> 1 ❑ Apartment/Condo <br /> 2 F1 Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility <br /> 1 1Restaurant/Bar/Dining <br /> 3 [0 Campground 7 ❑ Merchandise: Sales/Repairs ❑ <br /> bileom <br /> He Park 12 E] Service Station/Car Wash <br /> 4 ❑ Church/School 8 F1 Mo <br /> 5 [:] Hotel/Motel 9 ❑ office/Factory 13 El Other: specify <br /> EB) <br /> YPE O:ASanitary <br /> RMIT: (Check only one box on line A. Check box online B,if applicable) Repair of an <br /> 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5. ❑ g_y <br /> P , <br /> 1- � Tank Only Existing System __Existln S stem <br /> ----- m --------System -------------------------------- <br /> ❑ Permit was previously issued. Permit Number <br /> Date Issued <br /> V. TYPE OF SYSTEM: (Check only one) <br /> Other <br /> Non-Pressurized Distribution Pressurized Distribution Experimental <br /> 1 1 �J Seepage Bed 21 ❑Mound 30 E]Specify Type 41 E]Holding Tank <br /> 12 Seepage Trench <br /> 22❑In-Ground Pressure 42 E]Pit Privy <br /> 43❑Vault Privy <br /> 13[]Seepage Pit <br /> 14❑System-In-Fill <br /> VI. ABSORPTION SYSTEM INFORMATION: <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.) (�oifcti q O Feet �/(a.sFeet <br /> 45o (o�3 (e4b r <br /> VII. TANK Capacity Tot <br /> #Of Prefab Site Fiber- plastic Exper <br /> in gallons Manufacturer's Name Concrete Con- steel glass App. <br /> INFORMATION New Existin Gallons Tanks strutted <br /> Tanks Tanks <br /> Septic Tank or H&p6"+�enk 1000 ❑ <br /> Lift Pump Tank/Siphon Chamber <br /> VIII. RESPONSIBILITY STATEMENT <br /> lity for insta tion of the onsite sewage system shown on the attached plans. <br /> �}j sSignat (No Stamps) MP PR No.: Business Phone Number: <br /> Plumber' aL4 KING ROAD aa�F87y <br /> Plumber's 715 46 4030 ) <br /> IX. COUNTY/ DEPARTMENT USE ONLY <br /> 5d tar Permit Fes',(InducienGroundwater ate Issue ISSUing Ag Si atu mps) <br /> ❑Disapproved y. 9elee) <br /> �}�,4pproved ❑Owner Given Initial <br /> /V Adverse Determination -76 <br /> X. CONDITIONS OF APPROVAL/ REASONS FOR DISAPPROVAL: <br /> SBD 6398(R.05/94) DISTRIBUTION: Original to Cnunly,One copy To: Safety 9 Ruild ings Divuaon,owner,Plumber ___ <br />