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" ^ Safety and Buildings Division <br /> lk <br /> vyi��.r. 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 X03 Q <br /> than 8 112 x 11 inches in size. pp����ff <br /> • See reverse side for instructions for completing this application State Sanitary Permit Number <br /> The information you provide may be used b other government agency programs 3 a 7 � <br /> y p y y g 9 y p 9 ❑Check it revision to previous application <br /> [Privacy Law,s- 15-04(1)(m)L <br /> State Plan I.D.Number <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION I3l <br /> Property Owner NameProperty Location <br /> 1 WB <br /> � �/ lico v4 1/4,S /3 T 39 ,N, R /I/ E(or)9 <br /> Property Owner's Mailing Adaress Lot Number Block Number <br /> City_,Slate Zip Code Phone -o37Subdivision Name orCSM Number y <br /> II. TYPE OF BUILDING: (check one) ❑ State Owned ❑ City �J Nearest Roa-d <br /> E] Village /C'KSK 41.E <br /> Public 1 or 2 FamilyDwelling- No.of bedrooms Z own of <br /> III. BUILDING USE: (If building type is public,check all that apply) Parcel TaxNumber(s) <br /> 1 ❑ Apartment/Condo IDas/-�oiS%O/ 600 <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. VrReplacement 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 6. System Elev. 7. Final Grade <br /> l�j�}�� Required (sq. ft.) Proposed(sq.ft.) (Gals/day/sq.ft.) (Min./inch) Elevation <br /> 3 Feeti Feet <br /> TANK Capacity VII. INFORMATION in gallons Total #of Manufacturer's Name Prefab Con- Steel Fiber- Plastic Exper- <br /> Gallons Tanks concrete glass App <br /> New Existin strutted <br /> Tanks Tanks <br /> S�cirn oldi_ng ran /333./1! / �K1447/omJ /b ® El ❑41 r_1 r_1 El <br /> er �i/n.7 / �OIJ /b i ❑ ❑ ❑ ❑ ❑ <br /> VIII. RESPONSIBILITY STATEMENT <br /> I, s s' ility fpr inst ion of the onsite sewage system shown on the attached plans. <br /> Plumb l sSignat (No Stamps) MP/ PRS o.: Business Phone Number: <br /> 2453 KING ROAD aay�7rj <br /> Plumber's ): <br /> 715 468-40000% <br /> IX. COUNTY/ DEPARTMENT USE ONLY <br /> ❑Disapproved S itaryPermitFee (tnrludeseroundwdter atesu <br /> lse Issuing Age S1,61 p <br /> roved harge ree) <br /> pp ❑Owner Given Initial 17,50 7s ori /Q <br /> LID <br /> Adverse Determination / / `' <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: IY <br /> SRU`6398(R.05/94) 0MRIRUTION: Original to COUOty,One u,Py To: Sufety 8 Rvildings Die,von,Owner,Vlumhzr <br />