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0-n 65yyt_P1 <br /> W ar" Safety and Building Division <br /> 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 /> • Attach complete plans(to the county copy only)for the system,on paper not less count - t� <br /> than 8 1/2 x 11 inches in size. COY :Q,0 / Do <br /> • See reverse side for instructions for completing this application State Sanitary Permit Numbe <br /> The information you provide may be used by other government agency programs E]Che revr to pr ibus application <br /> [Privacy Law,s. 15.04(1)(m)]. <br /> State Plan LD_Number <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION <br /> Property Owner Name i roperty L cation `/ <br /> Rn 1/4�(f 1/4,S IT T 3q ,N, R / E(oreq <br /> Property Owner's Mailing Address Lot Number Block Number <br /> � <br /> Ci S ate ( Z/ Code Phone NumberSu ivision Name or CSMPumber <br /> S'zf la�S�lZ(o f0 <br /> II. PE OF BUILDING: (check one) ❑ State Owned ❑ city Nrest oad f� <br /> Public ❑ village <br /> ❑ ❑ 1 or 2 Family Dwelling- No.of bedrooms own OF <br /> III. BUILDING USE: (If building type is public,check all that apply) Parcel Tax^N�ummbber(s) /� <br /> 1 F1 Apartment/Condo ®�" ` — c L 4 o 1(Oo� <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. ❑ New 2. Replacement 3. Replacementof 4. E] Reconnection of 5. [:] Repair of an <br /> ------System __ stem _____ _ Tank Only _____ Existing 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 Xeepage 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 /> 140 System-In-Fill N �/ � /1 -10jC <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 /> Reqy_[red( . ft.) Proposed(sq.ft.) (Gals/day/sq.ft.) (Min./inch) Elevation <br /> T Z 3 Z a �'— Feet D , Feet <br /> C <br /> VII. TANK acct <br /> in a gallons Total #of Prefab Site Fiber- Ex er <br /> INFORMATION Gallons Tanks Manufacturer's Name Concrete Con- Steel Plastic p <br /> New Existin �.J,� oncrestrutted glass App <br /> Tanks Tanks . <br /> �Q�-�_ <br /> Septic Tank or Holding Tank �Q <br /> Lift Pump Tank/Siphon Chamber ❑ ❑ ❑ El El El <br /> VIII. RESPONSIBILITY STATEMENT <br /> I,the undersigned,assume responsibility for installation of the onsites wage system shown on the attached plans_ <br /> P ber'sName: Pn t) Plum r'sS- natur ( 05 ) /MPRSWNo.: Business Phone Number: <br /> 2gqz�o 71 <br /> lumber's Address(Street,City,S te,Zip Code): <br /> IX. COUNTY/ DEPARTMENT USE ONCY <br /> ❑Disapproved Sanitary Permit Fee des croundwarer ate Is ue Issuing Agent gnat a ps) <br /> proved surcharge f ee) <br /> p ❑Owner Given Initial ) C ffr� y 3/ .007 <br /> Adverse Determination 7 <br /> X.-CONDITIONS OF APPROVAL/ REASONS FOR DISAPPROVAL: <br /> �Oee ej;�jfv4b- exc�A <br /> el E <br /> WD-6398(11 0S/94) DISTRIRUT N: Original to(nura y,One copy To: Safety 8 Ruildingf Divumn,owner,Plumbar <br />