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�I <br /> Safety and Buildin s Division <br /> D:L Fill SANITARY PERMIT APPLICATION <br /> Bureau ofeuildingWaterSystem <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 C ty <br /> than 812 x 11 inches in size. G(rrl-I°T"� <br /> • See reverse side for instructions for completing this application State Sanitary Permit Number <br /> 8 x '7/3 <br /> The information you provide maybe used by other government agency programs E]Check if revision to previous application <br /> 1Privacy Law,s. 15.04(1)(m)I. State Plan I.D.Number I ,1 <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION S ' a 0-1 <br /> { W <br /> ZPr rty Owner N e PSoperty Location <br /> X <br /> !ii rw���. LV11/4 S E 1/4,S ( S T, 8" ,N, R $ Z- oro <br /> pe='s Nailing Adrless� Lot Number Block Number <br /> City,Stat�t� r. Zi Code Phon Number Subdivision Name or CSM Number <br /> G v tj t SAF��� (7r ) _zyo3 <br /> II. TYPE F BUILDING: (check one) E] State Owned It tN,earestt Road T <br /> ZZ ❑ Village I. OCV—( (V2 1� N . H I � 1)r. <br /> Public 1or2Famil Dwelling-No.ofbedrooms Town0FW <br /> III. BUILDING USE: (If building type is public,check all that apply) Parcel Tax Number(s) <br /> 1 ❑ Apartment/Condo Oq Z — Z5l S-- 03G(!�O <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. 0 Replacement 3. ❑ Replacementof q ❑ 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 C9 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. Pert. Rate 6. tern Et". Final Grade <br /> /6, f1C Required(sq.ft.) Proposed(sq. ft.) (Gals/day/sq. ft.) (Min./inch Elevation <br /> ,1 C � S'C� C r>`' r Z ?7 eet 16)0, Feet <br /> Capacity <br /> VII. TANK in gallons Total #of Prefab Site Fiber- plastic Exper <br /> INFORMATION New Exist in Gallons Tanks Manufacturer's Name Concrete Con- Steel glass App. <br /> Tanks Tanks strutted <br /> epY k or Holding Tank I Z-So iese Ca>•1C(-z ❑ ❑ ❑ ❑ ❑ <br /> K <br /> -ft Pu ank/Siphon Chamber 7� I ❑ ❑ ❑ ❑ ❑ <br /> VIII. RESPONSIBILITY STATEMENT <br /> I,the undersigned,assume responsibi Oty for installation of the onsite sewage system shown on the attached plans. <br /> Plumber's Name: Prin ) PI ber's Sionatur tamps) MP/MPRSWNo.: Business Phone Number: <br /> FSS ®ey !2t/� S7?S� d66- o <br /> Plumber's Address(Str et,City,State,Zip Co ): <br /> IX. COUNTY/ DEPARTMENT USE ONLY <br /> ❑Disapproved Sanitary Permit FeeU0ndudes Groundwater ate ue Issuing ure am <br /> tSi n ps) <br /> Approved ❑Owner Given Initial ��✓ ar9eree) <br /> Adverse Determination (J <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(R 05/94) DISTRIBUTION: 0rigi.1 m Cuuoiy.One<epy To: 50ety 8 Ruildi ,Di.,,w,,Owner,Plumber <br />