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22 <br /> Safetyand Buildings <br /> v�iLW�ri 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 /> 0 Attach complete plans(to the county copy only)for the system,on paper not less Co <br /> than 812 unt x 11 inches in size. n <br /> • See reverse side for instructions for completing this application State Sanitary PermitNumber O <br /> The information you provide may be used b other government agency programs ��v �� <br /> Y P Y Y 9 9 Y P 9 ❑Check i(revision to prow us application <br /> [Privacy Law,s. 15.04(1)(m)]. <br /> State Plan I.D.Numbed, <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INF RMATION <br /> Prope Owner Name Property Location <br /> 5411/4 1/4,S a U T `/`O •N, R/0' E(or)� <br /> Property Owne0os Mailing Address Lot Number Block NuInber <br /> S`r Vo-x 3 <br /> Cit ,State Zip C de Phone Number Subdivision Name or CSM Number <br /> yr g* S O f' (6S >5r6 ,3335" GJ/'l V/ol /fS.f <br /> I1. TYPE OF B DING: (check one) E] State Owned ❑ Ctyage Nearest Road <br /> Public 1 or 2 FamilyDwelling- No.bf bedrooms E] TViown OF 04CLkla4al All /PCS. <br /> III. BUILDING USE: (If building type is public,check all that apply) Parcel TaxNumber(s) �1 / <br /> 1 E] Apartment/Condo �r�0 ! v` /�- 1 `y 2 40 <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. g?New 2. E] Replacement 3. ❑ Replacement of 4_ ❑ Reconnection of 5. [:] Repair of an <br /> System System Tank Only Existing System 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 PSeepage 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/da /sq.ft.) (Min./inch) Elevation <br /> Feet 98,7e Feet <br /> TANK Capaut , <br /> VII. INFORMATION in allons Total #of Manufacturer's Name Prefab. Con Fiber- plastic Fxper- <br /> New Existin Gallons Tanks Concrete strutted steel glass App. <br /> Tanks Tanks oAnSY! <br /> Septic Tank or Holding Tank - o r ga­�- ❑ ❑ ❑ ❑ ❑ <br /> Lift Pump Tank/Siphon Chamber ❑ ❑ ❑ ❑ ❑ ❑ <br /> VIII. RESPONSIBILITY STATEMENT <br /> 1,the undersigned,assume responsibility for installation of the onsite sewage system shown on the attached plans- <br /> Plumber's Name:(Print) <br /> lans.Plumber'sName:(Print) Plumber's Signature:(No Stamps) MP/MPRSWNo.: Business Phone Number: <br /> /1P a 6 Q lis= �r0G- male <br /> Plumber's Addre s(Street,City,State,Zi C de):� <br /> (p Ch� � /Yr !CY V1,1, f e& <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> E]Disapproved Sanitary Permit Fee (includes Groundwater Date Issued Issuing Agen ignature(N Sta ps) <br /> roved arge Fee) <br /> App ❑Owner Given Initial � <br /> Adverse Determination � <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> cnn auoc ro ncna, ndcrnieunnu. n.:-:-m..,r-..-.., n--.- T. c..r-r.,s w..a.r.--.n.-..,... n...--, or.....w. <br />