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" Safety and Buildings Division <br /> SANITARY PERMIT APPLICATION Bureau of Building Water System <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 <br /> than 8lrz Y�x 11 inches in size. �URNE7T`r <br /> • See reverse side for instructions for completing this application State Sanitary Permit Number <br /> ,:R!R/ 7(7 c?-- <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)1. <br /> State Plan I.D.Number <br /> 1. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION <br /> Prop\.JOOwner Na E �ro. `I�a�n , � r� <br /> V�p+ 5 T ,N, R W <br /> Property Owner's Mailing Address Lot Number 81oek_NOT}fer <br /> /68/ S Vro IA lRbill .3 <br /> City, tate Zip Code Phone Number S,10 yi9ief+WalaB or CSM Number <br /> II. TYPE OFBUILDING: (check one) ❑ State Owned ❑ City Nearest Road 37.27 <br /> Public 1or2Famil Dwelling-No.ofbedrooms Z Village own OF SGKSDA) LOON .L+>FKE !PD <br /> III. BUILDING USE: (If building type is public,check all that apply) Parcel Tax Number(s) <br /> 1 ❑ Apartment/Condo <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. 04eplacement 3. ❑ Replacementof 4. ❑ Reconnection of 5. ❑ Repair of an <br /> System System 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-Pr surized Distribution Pressurized Distribution Experimental Other <br /> 11 Weepage 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 /> Requ�lf�ed�sq. ft.) Prop ^(sq. ft.) (Gals/day/sq. ft-) (Min./inch) Elevation <br /> 300 HLL/ W Z 9z•T Feet `FXF �JFeet <br /> Capacrt <br /> VII. TANK in allons Gallons Tanks c000ete Site Steel gals Plastic APPr <br /> INFORMATION ManufacturerTotal #of 's Name con- <br /> New Existin strutted <br /> Tanks Tanks <br /> Septic Tank or Holding Tank low Iwo is <br /> El El ❑ El 1:1Lift Pump Tank/Siphon Chamber �� J LJ ❑ ❑ I ❑ ❑ ❑ <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) u ber's SignatureNo Stamps) MP/MPRSW No.: Business Phone Number: <br /> �. �. � W1%� 1 /y9� �l5-L y- 3Y3 <br /> P er's Address(Street,City,sst t,. Zip Code): <br /> % PQ 4. <br /> IX. COUNTY/ DEPARTMENT USE ONLY <br /> [_1 Disapproved Sanitary Permit Fee (mdode,Groundwater Date Issue' <br /> ssue ISSU gA ent Sign or No Stamps) <br /> Approved surcharge reel <br /> pp ❑Owner Given Initial )6� M —�-� <br /> Adverse Determination <br /> X. ONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(R.05N4) DISTRIBUTION: originaltn Caunly,On.w,To: safety 6 Ruddin,Division,O..n ,,Plumber <br />