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OSafety and Buildings Division <br /> • ■■■^ Bureauof Bu ilding Water System <br /> SANITARY PERMIT APPLICATION . <br /> 201 E.Washington Ave. <br /> In accord with ILHR 83 05,Wis.Adm.Code P.O.Box)`969 <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 x 11 inches in size. I r <br /> • See reverse side for instructions for completing this application State Sanitar2tmit Nm uber JG,g/�j� <br /> 0q 1 1I C, <br /> The information you provide may be used by other government agency programs L]Check it rev sloe to previous application <br /> IPrivacy Laws. 15.04(U(m))_ State Plan 1. -Number <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION scl, - aOsibo <br /> Property Owner Name Property Location �1 <br /> -rA41 Av r -ja7 Ue.g /ri e- C-or A 1/4 1/4,5 ,"j, T03 ,N, R /9 E (or)tt„vi <br /> Propery Owner's Mailing Address Lot Number lock Number <br /> 16 o 7702 IF 1 <br /> City,State Zip Code Phone Number ubdi Nalene or CSM Number <br /> K X<I� G I F s 6 ) �3y-211" r-Aa F s y,v r --s e Al<!-4 <br /> II. TYPE OF BUILDING: (check one) ❑ State Owned it� Nearest Road <br /> ❑ Public 1 or 2 FamilyDwelling- No. of bedrooms oZ ❑ viz age nzJ �� <br /> Town OF /' ,�C e/U/c L�E4J <br /> III. BUILDING USE: (If budding type is public,check all that apply) Parcel TaxNumber(s) qITZY-0I- <br /> 1 ❑ Apartment/Condo <br /> _ `t/lJ <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 ❑ Servii 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, [X New 2_ ❑ Replacement 3. ❑ Replacement of 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 Pressurized Distribution Pressurized Distribution Experimental Other <br /> 11 ❑Seepage Bed 21 I&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 /> Required (sq. ft.) Proposed(sq.ft.) (Gals/day/sq. ft.) (Min./inch) Elevation/ <br /> asc X25.? /,� / /i Feet /ho0rvclFeet <br /> TANKCa acct <br /> VII. INFORMATION in gallons Total # of Manufacturer's Name Prefab to Fiber- plastic Exper <br /> New Existin Gallons Tanks Concrete stru ted Steel glass App. <br /> Tanks Tanks <br /> Septic Tank or Holding Tank /' OJl` �yL JR 1:1 El El ElLift Pump Tank/Siphon Chamber boo �gs L� El— 11 1 ❑ ❑ ❑ ❑ <br /> VIII. RESPONSIBILITY STATEMENT <br /> I,the undersigned, assume responsibility for installation of the onsite sewage system shown n the attached plans. <br /> Plumber's Name:(Print r / Plumber's Signature:(No Stamps) /MPRSW No : Business Phone Number: <br /> /111 1 <br /> Plumb is Addre§(Street,City,State.Zip Code): <br /> r L-' <br /> IX. COUNTY/ DEPARTMENT USE ONLY <br /> E]Disapproved Sam ary PermrtFee ilnciudce groundwater ate Issue Issul g Agent Signature(No Stam ps) <br /> LApproved [ S.1thorge tee) <br /> ❑Owner Given Initial clL <br /> Adverse DetermiaMCC QS 4QG'v� ��Ze7IJ <br /> nation N <br /> X. CONDITIONS OF APPROVAL/ REASONS FOR DISAPPROVAL: <br /> SHE'b39B(it 05194) DISTRIBUTION. Original to Cmioly,One<npy, To: Sulety Is fl,uWings nivumn,Owner,Plum r <br />