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Safety anduildi�vision <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 County <br /> than 8 112 x 11 inches in size. (( // 7 <br /> • See reverse side for instructions for completing this application 5 ate 5anitarYPer itNu3r <br /> The information you provide may be used by other government agency programs ❑Check it revision to previous application <br /> [Privacy Law,s. 15.04(1)(m)I. State Plan I .Number <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION <br /> Property Owner Name Propert o tion <br /> ON 1/4 v4,S p T44 N, R � E(o W <br /> P rope rt wner's Mailing <br /> ddress /7/2 of Number Block Number <br /> ty, Zip Code 7 N' Phone Number <br /> F11J <br /> WI AXE-E ,5"g�a3 <br /> II. TYPE BUILDING: (check one) ❑ State Owned ❑ cit Nearest Road <br /> ❑ <br /> Villa jWISS <br /> Public 1 or 2 FamilyDwellingge '- No.of bedrooms � town of / L-b <br /> III. BUILDING USE: (If building type is public,check all that apply) P rcelTaxNumber(s) <br /> 1 ❑ Apartment/Condo 3z 5X30 D f 'OD <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. D4 Replacement 3_ ❑ Replacement of 4_ ❑ Reconnection of 5. ❑ Repair of an <br /> System System Tank Only_____ Existing System ____ExistingSystem <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 bd Seepage 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 /> 30o Req fired(sq.ft.) Proposed(sq. ft.) (Gals/day/sq.ft.) (Min./inch) Elevati n <br /> L� ,7 �"—" o Feet q-� Feet <br /> Ca act <br /> VII' INFORMATION in gallons Total #of Manufacturer's Name Prefab. Con1,1e- Steel Fiber- Plastic Exper. <br /> New Existin Gallons Tanks concrete structed glass App <br /> Tanks Tanks <br /> Septic Tank or Holding Tank ❑11 VV ❑ ❑ ❑ ❑ <br /> Lift Pump Tank/Siphon Chamber ,�Q 0 ❑ ❑ ❑ ❑ 11 <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:(Pn t) Plumber' Signature' (N tamps) MP/MPRSW No.: Business Phone Number: <br /> c�jAt2v Kl�l <br /> P m ber's Address(Street,City,State,Zi Code): <br /> 'L"1I( o 5 �85TE W 1 • 5 8`�3 <br /> IX. COUNTY/ DEPARTMENT USE ONLY <br /> El Disapproved Sanitary Permit Fee li"dudeseroundwater ate Issue ssuin A ent ign (No Stamps) <br /> *Approved urc❑Owner Given Initial O � <br /> Adverse Determination <br /> X. CONDITIONS OF APPROVAL/REASONS F SAPPROVAL: <br /> SMD-b398(R.05/94) DIS rN18UT10N Original to county.One u>py To- Sniety 8 NuilJingi Dimvon,Owneq Plumtur <br />