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(infety and Buildings Division <br /> SANITARY PERMIT APPLICATION BureauBuilding Water Systems <br /> 200E.WaingtnAv <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 <br /> than 812 x 11 inches in size. &,p4)C-77 ' ::;�C;� tt C1 <br /> • See reverse side for instructions for completing this application State Sanitary Permit JJumtfer�& <br /> The information you provide may be used by other government agency programs E]Check if revision to previous application <br /> [Privacy Law,s. 15.04(1)(m)]. State Plan I.D.Number ,]/ <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION /r' <br /> Property. caner Name . Property Location <br /> cL(q /NET14 Nw1/4,S a 3 T ,N, R E(or) <br /> Property Owner's Mailing Address /� Lot Number Block Number <br /> 92Zl/O>ac? ST R6IEp� E N. <br /> City,State Zip CodePhone Number Subdivision Name or CSM Number <br /> II. TYPE OF BUILDING: (check one) ❑ State Owned ❑ City Nearest Road <br /> ❑ Public 1 or 2 Famil Dwellin - No.of bedrooms ~T t owns pF Sok t-'�� S-mar- 3� <br /> III. BUILDING USE: (If buildingtype is public,check allthatapply) Parcel TaxNumber(s) <br /> s3� -oa —Zoe <br /> 1 ❑ Apartment/Condo 03z 3 <br /> 2 ❑ Assembly Hall 6 ❑ Medica[ 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.Y,�L Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5- ❑ Repair of an <br /> System ystem 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 /> 1 1XISeepage 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 /> Requir d (sq. ft.) Proposed(sq.ft.) (Gals/day/sq.ft.) (Min./inch) Elevation <br /> �/,_3 Feet 9,>.0 Feet <br /> Ca acit <br /> VII. INFORMATION in gallons Total #of Manufacturer's Name Prefab. Site Con- Steel Fiber- Exper <br /> Gallons Tanks Concrete glass Plastic App <br /> New Existin strutted <br /> Tanks Tanks �} <br /> Septic Tank or Holding Tank ?�Q 7 (� 1�� X�Wavr El ❑ El ❑ 1:1 <br /> I ift 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 /> Plumber's Name:(Print) Plu r - na re-( Sta ps MP/MPRSW No.: Business Phone Number: <br /> ze. A t- �Q -7 s� 24ff,1C35ej <br /> Plumber's Address(Street,City,State,Zip Code): <br /> J67/3 L w- O <br /> IX. COUNTY/ DEPARTMENT USE ONLY <br /> ❑Disapproved Sanitary Permit Fee (InciudesGroundwater ate Issued Issuing gen Signature St <br /> Approved .y Y urcharge Fee) <br /> pp ❑Owner Given Initial /✓l �j�-/9-Qr�J <br /> Adverse Determination /Cres� l <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SHO-6398(R.05/94) DISTRIBUTION_Original to Cnunl y.One copy To: Salety&Buildings Oivnion,Owner,Plumber <br />