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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 8 112 x 11 inches in size. 4 n r ' <br /> • See reverse side for instructions for completing this application State San ry P*rr itt Number <br /> The information you provide may be used by other government agency programs ❑Check if revision to previous application <br /> [Privacy Law,s. 15.04(1)(m)I. State Plan I.D.Number <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION <br /> Property Owner Nam Property Location <br /> c c 1/4 1/4,S 13 T '6 ,N, R IS—E(or <br /> Property Owner's ading Address Lot Number Block Numbe <br /> �f 2r li nAve• -So- 3 /Y <br /> City,State Zip Code Phone Number Subdivision Name or CSMNum ber <br /> O LS- 6 LS / <br /> II. I YPE OF ILDING: (check one) ❑ State Owned L] ar, ^ ' Nearest Road <br /> E] Vol lage <br /> Public EyTor2 Famil Dwellin - No.of bedrooms own or Q K �i e /�C✓ <br /> III. BUILDING USE: (If building type is public,checkallthatapply) Parcel TaxNumber(s) 7 /r5 <br /> 1 E] Apartment/Condo e/p2 — L Z /3 _ 63 - ( 6 9- <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 /> qj 1. ( 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 []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 16. System Elev. 17. Final Grade <br /> Required (sq. ft.) Proposed(sq.ft.) (Gals/day/sq.ft.) (Min./inch) Elevation <br /> 3003 — y6` 6UFeet 99a�Feet <br /> Ca acit <br /> VII. TANK in gallons Total #of Prefab Site Fiber- Exper. <br /> INFORMATION Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App <br /> New Existin strutted <br /> Tanks Tanks <br /> Septic Tank or Holding Tank �G^eerr .- ❑ ❑ ❑ ❑ ❑ <br /> Lift 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) Plumber's Signature: Stamps) MP/MPRSW No.: jL7J,?6,6— &61e <br /> ess Phone Number: <br /> z a e, T ✓��n r �c 6 73 <br /> PIu ber'sAddrers(Street,Cit ,State,Zip Cod ): / -!. /� / _ <br /> i/! a ( i�6 J l rY /vlJ. <br /> IX. COUNTY/ DEPARTMENT UVE ONLY <br /> ❑Disapproved Sanitary Permit Fee 0ndudes Groundwater ate sue Issuing Age tsig ture( o amps <br /> roved Surcharge fee) /} <br /> pp ❑Owner Given Initial <br /> Adverse Determination <br /> X. CONDITIONS OF APPROVAL/ REASONS FOR DISAPPROVAL: It <br /> SHO 6398 Ot 05194) DISTRIBOTION: 0ngina1t0Coanly.Onetopy To: Safety&Buildings Division,Owner,Plumber <br />