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On enlwl <br /> Safety and Buildings Division <br /> Bureau of Building Water System. <br /> •- -- SANITARY PERMIT APPLICATION 201 E Washington Ave <br /> In accord with(LHR 83 05,Wis.Adm.Code PO.Box 7969Madison,WI 53707-7969 <br /> • Attach complete plans(to the county copy only)for the system,on paper not less County � �6 �� <br /> than 8 trz x 11 inches in size. State Sanitary Permit Number <br /> • See reverse side for instructions for completing this application /e <br /> The information you provide may be used by other government agency programs ❑ <br /> Cheeon 16-previous application <br /> (Privacy Law,S. 15.04(1)(m)I State Plan I.D.Number, / <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION <br /> Property Location <br /> Property Owner Namg / 1/4 1/4,S 1'I T �( ,N, R /,r'"'E(Or <br /> Property Owner's Mailing Addres{ Lot Number Block Number <br /> or I <br /> Cit State- Zip Code Phone Number' Subdivis�o�Name or CSM Number <br /> State Owned y Nearest Road <br /> II. TYPE OF BUILDING: (check one) ❑ ❑ Village <br /> ❑ Public 1 or 2 Family Dwelling- No.of bedrooms ❑ own OF <br /> Parcel Tax Number(s) <br /> .II. BUILDINGUSE: (If building type is public,check all that apply) J <br /> O 3rfl ?5 837c7Z d 3 ' <br /> 1 ❑ Apartment/Condo 10Outdoor Recreational Facility <br /> 2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 11 ❑ Restaurant/Bar/Dining <br /> 3 E] Campground 7 ❑ Merchandise: Sales/Repairs ❑ <br /> 12 ❑ Service Station/Car Wash <br /> 4 ❑ Church/School 8 ❑ Mobile Home Park 13 ❑ Other: specify <br /> 5 ❑ Hotel/Motel 9 ❑ Office/Factory <br /> IV- TYPE OF PERMIT: (Check only one box on line A- Check box on line B, if applicable) Repair of an <br /> Replacement 3. Replacement of - 4. ❑ Reconnection of 5. ❑ p . <br /> A) 1. New 2. ❑ p ❑ Tank Only Existing System Existing System <br /> stem System ___________y_____ <br /> Date Issued <br /> B) ❑ A Sanitary Permit was previously issued. Permit Number <br /> V. TYPE OF SYSTEM: (Check only one) <br /> Experimental Other <br /> Non-Pressurized Distribution Pressurized Distribution P <br /> 21 Mound 30❑Specify Type 41 E] Holding Tank <br /> 1 1 Seepage Bed ❑ 42 El Pit Privy <br /> 12❑Seepage Trench 22❑In-Ground Pressure 43❑Vault Privy <br /> 13[]Seepage Pit <br /> 14❑System-In-Fill <br /> VI. ABSORPTION SYSTEM INFORMATION: <br /> 1- Gallons Per Day de <br /> 2. Absorp.Area 3. Absorp.Area 4. Loading Rate 5. Perc. Rate 6. System Elev. Elev7. ma nraK <br /> Requir d(sq.ft.) Proposed(sq.ft.) (Gals/da .ft.) (Min./inch) p I �� Q <br /> �-- f�- Feet Q®- Feet <br /> VII. TANK Capauty Total #of site F;ber_ Exper- <br /> ingallons Manufacturer's Name Concrete este Con- Steel glass Plastic App <br /> INFORMATION New Existin Gallons Tanks strutted <br /> Tanks Tanks <br /> Septic Tank or Holding Tank 750 <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 /> Plumb re: o$�a s) P/MPRSWNo.: Business Phone Number: <br /> Plumber's Name:(Pnnt) ;7 <br /> Plumber's Address(Street,City,State,Zip Code): <br /> eLl4w "3s- <br /> IX. COUNTY/ DEP DEPARTMENT USE ONLY <br /> ❑Disapproved Sanitary Permit Fee I1ncI dans roundwaler ate Issue suing Agen ignature(N S ps) <br /> Surcharge elee) <br /> 0approved ❑Owner Given Initial /6-D _ <br /> � Adverse Determination <br /> X. CONDITIONS OF APPROVAL/ REASONS FOR DISAPPROVAL: <br /> DISTRIRUTION-. Original to emuAy,One<npy To' Sulety&Ruildings Division,owner,Plumber <br /> -���6398(R.OSi94) - <br />