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Safety and Division <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 12 x 11 inches in size. �uW r1urb4 <br /> • See reverse side for instructions for completing this application StateSanitar Permit Number <br /> �3�� 5 <br /> The information you provide maybe used by other government agency programs Ej Check it revision to previou application <br /> ]Privacy Law,s- 15-04(1)(m)]. <br /> State Plan I.D.Number <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION I <br /> Property Owner N Property Location <br /> IT1 r'R i (IE 1/4 ()e 1/4,S I$ T 38 IN, R I`F E(or)ow <br /> Property Owner's Mailing Address Lot Number Block Number <br /> 3112 E. 33r_J 4. CLS <br /> City,State I Zip Code Phone Number Subdivision Name or CSM Number <br /> �S Mn 59406 ( bIZ)"tZ2- i <br /> II. TYPE OF BUILDING: (check one) r Mate Owned ❑ City Nearest Road <br /> village r� <br /> Public 1 or 2 FamilyDwelling- No_of bedrooms -3_ 2C1,Town OF rooe�riRE"IRIL. <br /> III. BUILDING USE: (If building type is public,check all that apply) Parcel TaxNumber(s) <br /> 1 ❑ Apartment/Condo 609--r-7, 116— 0//00 <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. ❑ Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an <br /> ------System --------SystemTank Only Existing System ------Existing 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 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 /> �� Required (sq. ft.) Proposed(sq.ft.) (Gals/day/sq. ft.) (Min./inch) Elevation <br /> 455) ftloo- h 4R 1.3 Feet Feet <br /> VII. TANK Capacity <br /> INFORMATION in gallons Total #of Prefab. Ate Steel Fiber- plastic Exper <br /> Gallons Tanks manufacturer's Name concrete Con- glass App <br /> New Existin strutted <br /> Tanks Tanks <br /> Septic Tank or W&W"yg-T� 1000 Oo ® ❑ ❑ ❑ ❑ ❑ <br /> Lift Pump Tank/Siphon Chamber ❑ ❑ ❑ ❑ ❑ ❑ <br /> VIII. RESPONSIBILITY STATEMENT <br /> I,the undersigne ,a e respons' ility for installation of the onsite sews e s stem shown on the attached plans. <br /> Plumber's Na�� EXCAVATt er s Signat e:(No Stamps) P PRS o.: Business Phone Number: <br /> wA4_1+JA1),,A O�—J r <br /> �a <br /> N620 C <br /> Plumber's Address. ode): <br /> M51 835-7482 <br /> IX. COUNTY/ DEPARTMENT USE ONLY <br /> ❑Disapproved Sa utary Permit Fee (Induden Groundwater Date Issued Issuing Agent Signature Up Synpsl <br /> proved ❑ )urchargefee) <br /> ( 'P Owner Given Initial �w g <br /> V Adverse Determination <br /> X. CONDITIONS OF APPROVAL/ REASONS FOR DISAPPROVAL: <br /> SHD-6398(R.05/94) DISTRIBUTION: Original to County.One Copy To: Safety 8 Buildings Division,Owner,Plumt,2r <br />