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Safety and Buildings Division <br /> vi�`•.'F'i SANITARY PERMIT APPLICATION Bureau of Budding 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 County �� �� <br /> than 8 112 x 11 inches in size. ttl he. <br /> jf• See reverse side for instructions for completing this application State Sanitary Permit Number <br /> The information you provide may be used by other government agency programs 6-6 90/ <br /> � ,J� ) ❑Check d revision 10 previous application <br /> (Privacy Law,s. 15.04(1)(m)l. �joa uTL 0 State Plan LD.Number <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION <br /> PropertyO rN a Property Location �� _^�' /,� <br /> 6TI a w, mo �+ 1/4 1/4,S T3_7,N, R 1/ p(or)W <br /> Prope%yy net' Mailing Addresb �/ �� Lot Num bet Block Number <br /> 7 7 3 G rV � <br /> Cty,State Zip Cod Phone Number Subdivision Name or CS7Number <br /> ue Wr 6-.3 c�/;') .t - fs : // ew 11'. e. <br /> II. TYPE UFBUIL ING: (check one) E] State Owned E] CaNearest Road t� / <br /> Public 1 or 2 Family Dwelling-No.of bedrooms town of A a <br /> III. BUILDING USE: (If buildingtype is public,check all that apply) Parcel Tax Number(s)) o3 - L707�=0/ aoe' '><' <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. QReplacement 3. ❑ Replacementof q ❑ Reconnection of S. E] Repair of an <br /> ------System System --- Tank Only - - Existing System - Existing <br /> Y <br /> 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 /> 11 [:]Seepage Bed 21A 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 1 <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 /> 20o Required (sq. ft.) Proposed(sq.ft.) (Gals/day/sq. ft.) (Min./i ch) Q et Elevation <br /> 115's-0 .X ,2� �S—o? .;2 / 9.36 FeI0/.SJ Feet <br /> TANKCa act <br /> VII. INFORMATION n gallons Total #of Manufacturer's Name Prefab Con- Fiber- plastic Exper <br /> New Exist in <br /> Gallons Tanks Concrete Steel glass App. <br /> Tanks Tanks strutted <br /> Septic Tank or Holding Tank 1 c ,o [I [j 1:1 1:1 <br /> -70 <br /> Lift Pump Tank/Siphon Chamber IN ❑ ❑ ❑ ❑ ❑ <br /> VIII. RESPONSIBILITY STATEMENT <br /> I,the undersigned, assume responsibility for install 'on of the onsite sewage system shown on the attached plans. <br /> Plumber's me:(Print) PI b 's Sig ture: oSta /MPRSW No.: Business Phone Number: <br /> }�.4 w oh a 3 3�� 7/��- r— <br /> Plumber'sA dress(Street,City,State Zip Code): <br /> C W / <br /> IX. COUNTY/ DEPARTMENT USE ONLY <br /> \/ ❑Disapproved Sanitary Permit Fe Bnduder Groundwater ate Ssue Issuing Sig ture tamps) <br /> L�X6proved ❑Owner Given Initial ')b 0y"s°r<nar9eree) / !�/ y/ <br /> TTT��\ Adverse Determination o� �� �!IVF61 <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> Sim 639B(R.OSN4) DISTRIBUTION: Original ro Coumy,One,.,To: Safety 8 Ruildingf Oiwalon.Owner,Plumber <br />