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Safety and Buildings Division <br /> SANITARY PERMIT APPLICATION Bureau of Building Water Systen <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 �u <br /> than 8 112 x 11 inches in size. <br /> • See reverse side for instructions for completing this application State Ste— <br /> ai Ita y Pe mit Number 52��� <br /> � <br /> The information you provide maybe used by other government agency programs ❑C leekk T revislu previous application <br /> [Privacy Laws. 15.04(1)(m)I- State Ple nI.D-Number <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION <br /> Prop�^Owner Name Property`LoSation o <br /> eS. C_ O M NEl/4 S W 1/4,S I D T q0 ,N, R /6 E(or) <br /> Property Owner's Mailing Address Lot Number Block Number <br /> XC) <br /> City,State Lp Code Phone Number Subdivision Name or CSM Number <br /> 1. <br /> 11, TYPE OFBUILDING: (check one) ❑ State Owned ❑ City Nearest Road �^ <br /> ❑ Village 0 ills � /c✓- <br /> ❑ Public 1 or 2 FamilyDwelling- No. of bedrooms �- Town of /✓0 <br /> III. BUILDING USE: (If building type is public,check all that apply) Parcel Tax Number(s) <br /> 1 ❑ Apartment/Condo -Z— `7 30- <br /> 2 <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: ( on y o` on line A. Check box on line B,if applicable) <br /> A) 1 ❑ New ( Replacement 3_ ❑ Replacement of 4_ ❑ Reconne tion of 5_ ❑ Repair of an <br /> System System Tank Only _________Existing ystem Existing System <br /> B) ❑ A Sanitary Pe itwas previously issued Permit Number Date Issued <br /> V. TYPE OF SYSTEM: (Check only one) <br /> Non-Pressurized Distribution Pressurized Distribution Experimental Other <br /> t 1eepage Bed 21 ❑Mound 30 F]Specify Type 41 E] Holding Tank <br /> 12 Seepage Trench 22 F1In-GroundPressure 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 I S. Perc. RatE 6. System Elev. 7. Final Grade <br /> Required(sq. ft.) Proposed (sq. ft.) (Gals/day/sq.ft.) (Min./inch) Elevation <br /> '50o 375 37.S $ $ . Feet qs. q Feet <br /> VII. TANK Capacity Site <br /> INFORMATION in gallons Galltons Tal anks Manufacturer's Name Cornc et Con- Steel glass- Plastic App <br /> New Existing strutted <br /> Tanks Tanks CQ ❑ 0 El El ❑ <br /> Septic Tank or Holding Tank -7572 .� I <br /> Wt PumpTank/Siphon Chamber El ❑ El ❑ 1-1 C <br /> VIII. RESPONSIBILITY STATEMENT <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 (N tamps) MP/MPRSWNo.: Business Phone Number: <br /> 7u4A9.0 v IIJS + id 3 z� IS- c�fo6- ISS <br /> Plumber's Address(Street,City,Stat .Zip Code): <br /> z bo W ITi3r� Ij(. s s9s <br /> IX. COUNTY/ DEPARTMENT USE ONLY <br /> ❑Disapproved Sanit ry Permit Fee linguae G,ouooe,ater ate Issue Issuin Tit Signa re(No Stamps) <br /> fee) <br /> pproved ❑Owner Given Initial I Sb M Surcharge <br /> Adverse Determination <br /> X. C NDITIONS OF APPROVAL/ REASONS FOR DISAPPROVAL: <br /> SBD 6398(R.05/94) DISTRIBUTION'. Original m County.One copy To: S..lety&kuildlnys Diw!ion,Owner Plumber <br />