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�■ Safetyand Buildings Division <br /> mum SANITARY PERMIT APPLICATION Bureau of Building Water Systems <br /> In accord with ILHR 83.05,Wis.Adm.Code 201 E.Washington Ave. <br /> P.C1 Box 7969 <br /> Madison,WI 53707-7969 <br /> • Attach complete plans(to the county copy only)for the system,on paper not less Cou ty <br /> than 8 v2 x 11 inches in size. oucl r e ffQv lk. <br /> • See reverse side for instructions for completing this application State Sanitary Permit Number <br /> The information you provide may be used by other government a3c /6 77 <br /> enc <br /> !Privacy Law,i 15.04(1)(m)). g y programs ❑Check if revision to previous application <br /> State Plan I.D.Number O <br /> I. APPLICATION INFORMATION- PLEASE PRINT ALL INFORMATION (� � <br /> Pro erty Owner Name Property Location XJ <br /> DAUi. N'dersoit) 1/4 1/4,S3S! T fb ,N, R /$ E(or)W� ( ) <br /> Property Owner's Mailing Address Lot Number„,, <br /> /6 7o C T f_! jy37 <br /> lBlocumber <br /> C ee.tte/C6)� � )Phone Number Subdivision Name or CSM Number r2 i n /i / <br /> Gr I Asa?/ 7�3 7 /v^ . L. I <br /> I. TYPE OF BUILDING: (check one) 0 State Owned ❑ City `'(�' Nearest Road <br /> 0 Public 5. 1 or 2 Family Dwelling-No. of bedrooms e2 �rowageOF V A-C- c$Ott) j 1D s g-/ <br /> III. BUILDING USE: (If building type is public,check all that apply) Parcel Tax Number(s) <br /> 1 ❑ Apartment/Condo /a ` 14 3Lf- 0J-� <br /> 2 ❑ Assembly Hall 6 0 Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility <br /> 3 0 Campground 7 0 Merchandise:Sales/Repairs 11 0 Restaurant/Bar/Dinin <br /> 0 Church/School 8 0 Mobile Home Parkg <br /> 4 <br /> 12 0Service 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. a New <br /> 2. ❑ Sytem Replacement 3. ❑ Replacement of 4_ ❑ Reconnection of 5 Repair of an <br /> Tank Only Existin ,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 XSeepage Bed 21 ❑Mound 30❑Specify Type 41 ❑Holding Tank <br /> 12 0 Seepage Trench 22 0 In-Ground Pressure <br /> 13❑Seepage Pit 42❑Pit Privy <br /> 14❑System-In Fill 43❑Vault Privy <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 /> �D� Required(sq_ ft.) Proposed(sq. ft.) (Gals/day/sq.ft.) (Min./inch) �� Elevation <br /> 07 Feet 97 3 Feet <br /> VII. TANK Capacity , <br /> INFORMATION in gallons Total #of re . Site Figlasser- EAP Plastic p <br /> Tanks Tanks strutted <br /> Septic Tank or Holding Tank 75-0 75 , r7 El El ❑ I IDEllift Pump Tank/Siphon Chamber J I ❑ 0 <br /> _ Eli El STATEMENT <br /> VIII. RESPONSIBILITYi <br /> I,the undersigned,assume responsibility for installation of the onsite sewage system shown on the attached plans. <br /> Plumber's Name:(Print) Plumber's Signature:( o Stamps) MP/MPRSW No.: Business Phone Number: <br /> Plumber'sw � R y s4,i/� f ‘/ .�3 Address(Street,City,State,Zkp Code): �� <br /> 4 dermil' J-Cl/`e/0 / .5 � <br /> —c17 <br /> IX. COUNTY/DE ARTMENT USE ONLY <br /> ❑Disapproved SanitaryPermit Fee (includes Groundwater 'Date Issued <br /> Issuing A ent natur . j •s) <br /> ved ❑Owner Given Initial Surcharge lee) <br /> Adverse Determination /,* /dt/-Vg7 4A' <br /> i 1: <br /> X. CONDITIONS OF APPROVAL/REASONS FOR ISAPPROVAL: <br /> 580-6398(H.D5194) DISTRIBUTION: Original to County,One copy To: Safety 8 Buildings Division,Owner,Plumber <br />