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••" <br /> SANITARY Safety and BuildingsDrvlsion <br /> PERMIT A <br /> Bureau of Building Water Systerr <br /> In accord with ILHR 83 05,Wiz-Adm.Code 201 E Washington Ave. <br /> P O.Box 7969 <br /> • Attach complete plans(to the county copy only)for the system,on paper not less County Madison,WI 53707-7969 <br /> than 8 112 x 11 inches in size. <br /> • See reverse side for instructions for completing this application s ate sayaarytPPPer t r�v_mber <br /> The information you provide may be used by other government agency programs 8 Cl 7� <br /> lPrivacy Law,S. 15.04(1)(m)1. ❑Check i)revision to previous application <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION State Plan I.D.Number <br /> Property Owner Name <br /> Property Location <br /> t/4 1/4,S 3Z T Block N, N, R ` E(or <br /> Property OwneM Mail ingAddress Lot Number <br /> 6 90 umber <br /> CITY,State Zi C�� Phone Number Subdivision Name or CSM NumberANAM L~—. <br /> .J l! L (5v —2 R G5T, S <br /> . TYPE Or UILDING: (check one) ❑ State Owned ❑ city Nearest Road <br /> ❑ Public 1 or 2 FamilyDwelling- No.of bedrooms ❑ Town village <br /> OF �� _ <br /> III. BUILDING USE: (If building type is public,check all that apply) Parcel Tax Number(s) //�� <br /> 1 ❑ Apartment/Condo Z D q ZY 0Z SDO <br /> 2 ❑ Assembly Hall 6 p Medical Facility/Nursing Home 10 <br /> 3 Campground El Outdoor Recreational Facility <br /> ❑ p9 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 <br /> System ❑ 5. ❑ Repair of an <br /> _------y ------ 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 Dd Seepage Bed 21 ❑Mound 30❑Specify Type 41 ❑Holding Tank <br /> 12❑Seepage Trench 22❑ In-Ground Pressure <br /> 13 E]Seepage Pit 42 E]Pit Privy <br /> 14❑System-In-fill 43❑Vault Privy <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 /> 3c Req fired(sq. ft.) Prop sed sq. ft.) (jals/day/sq.ft.) (Min./inch <br /> Z ) Elevation <br /> Feet <br /> VII. TANK Capacity <br /> Feet <br /> INFORMATION in gallons Total #of Prefab Site <br /> Gallons Tanks Manufacturers Name con_ Fiber- Plastic Exper. <br /> New Existin Concrete stru<ted Steel glass App_ <br /> Tanks Tanks <br /> Septic Tank or Holding Tank d ❑ ❑ ❑ ❑ ❑ <br /> l'ft <br /> Pump Tank/Siphon Chamber �7 ❑ ❑ ❑ ❑ ❑ 0 <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) 1 Plumber tur ( Stamps) MP/MPRSW No.: I Business Phone Numper, <br /> P m er's Address(Street,City, te,Zip Code): Jer <br /> S 141503r,91? W)- SqS 3 <br /> IX. COUNTY/ DEPARTMENT USE ONLY <br /> ❑Disapproved Sanitar Permit Fe (Indudes Groundwarer ate Issue <br /> Approved y surcharge ree) /� Issuing A e gna ore( mps <br /> ❑Owner Given Initial �� if/f <br /> Adverse Determination 6� <br /> X. CONDITIONS OF APPROVAL/REASONS FM DISAPPROVAL: <br /> WD6398(M.05/94) DISTRIBUTION. Original to Cnuety,One copy To: Safety&Ruildinge Diveion.Owner,Plumber <br />