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C-kyj"w <br /> Safety and Buildings Division <br /> ■ ■■� SANITARY PERMIT APPLICATION Bureau <br /> �,I14��'1 201 E.WaaBuildingWaterSystem <br /> shington 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 Countyg -20 Q <br /> than 8 12 x 11 inches in size. <br /> • See reverse side for instructions for completing this application State Sanitary Permit Number <br /> a � 07/6 <br /> The information you provide may be used by other government agency programs ❑Check if revision to previous application <br /> 'IPrivacy Law,s. 15.04(1)(m)l. State Plan I.D.Number <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION 1_C� <br /> Property Owner Name J Property Location <br /> vy � 1/4 1/a,S T N, R/ E(or VV J <br /> Pro erty wner's Mailing Address Lot Numb I/� Block Number <br /> City,State Zip Code Phone Number Subdivision Na umber <br /> II. TYPE OF BUILDING: (check one) ❑ State Owned ❑ city , Neearest Road <br /> ❑ Village {/Z1Zl <br /> Public 1 or 2 Family Dwelling- No.of bedrooms AdIiQvvn <br /> III. BUILDINGUSE: (If building type is public,check all that apply) arcVNumbM)1 ❑ Apartment/Condo2 ❑ Assembly Hall 6 ❑ Medical Facility/ rsin e ❑ Outdoor Recreational Facility <br /> 3 ❑ Campground 7 ❑ Merchandise: es Rep ❑ Restaurant/Bar/Dining <br /> 4 ❑ Church/School 8 ❑ MobilWiome rk ❑ Service Station/Car Wash <br /> 5 ❑ Hotel/Motel 9 ❑ Office/Factory E] Other: specify <br /> IV. TYPE OF PERMIT: (Check only one n It A. b n line ,if applicable) <br /> A) 1 New 2. ❑ Replacem t Repl ment of 4. ❑ Reconnection of 5. ❑ Repair of an <br /> System Syste ank_ Iy______________ Existing System...............EgSystem <br /> B) ❑ A Sanitary Permit was pr iously d--- <br /> Permit Number Date Issued' <br /> V. TYPE OF SYSTEM: (Che ly ne) <br /> Non-Pressurized Distrib ion essuNistribution Experimental Other <br /> 11 ®Seepage Bed 1 and 30❑Specify Type 41 E]Holding Tank <br /> 12 E]Seepage Trenc 2 E]In-GroundPressure 42❑Pit Privy <br /> 13❑Seepage Pit 43❑Vault Privy <br /> 14❑System-In-Fill <br /> VI. ABSORPTION SYSM INF MATION: <br /> 1. Gallons Per Day 2. <br /> so <br /> rea 3. Absorp.Area 4. Loading Rate 5. Perc. Rate 6. System Elev. 7. Final Grade <br /> Req re sq.ft.) Proposed(sq.ft.) (Gals/day/sq.ft.) (Min./inch) Elevation <br /> p r� .5'' Feet 981 Feet <br /> VII. TANK Capacity Site <br /> in gallons Total #of Manufacturer's Name Prefab. Con- Steel Fiber- Plastic Exper <br /> INFORMATION New ExistingGallons Tanks Concrete strutted glass App <br /> Tanks Tanks <br /> Septic Tank or Holding Tank ,Felt, O O <br /> Q e 9-- n E El <br /> Lift Pump Tank/Siphon Chamber ❑ ❑ El 11 ❑ D <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.: Business Phone Number: <br /> L✓�g�� �fl n�.+1 ��'-^Jz.�C- � �—r�.� .��(� � •,�I�'lam'`��2�6 <br /> Plumber's Address(Street,City,Stat,Zip Code): <br /> dc� r 5'/ _!5�, ^ V t G✓Z `� '7 <br /> IX. COUNTY/ DEPARTMENT USE ONLY <br /> El Disapproved S <br /> Initial Sanitary Permit Fee (Includin roundwater at isue Issuin Ag Sign lure( S ps) <br /> - 31st'-r�L Surcharge Fee) <br /> pproved I / <br /> ❑Owner Given nitZy <br /> Adverse Determination C1Cr� <br /> f7 <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> N owrlPRs: kjcl -4- &ar&,r Andl?j'Sa,-1 <br /> S74s -,�kIST eve.S. 6,a_-? a_171 <br /> /ap/s., mel/ �r Z 0)-, /a>� <br /> SBD-6398(R.05/94) DISTRIBUTION: original to County.one copy To: Surety b Ruildings Division,Owner,Plumber <br />