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Safety and Buildings Division <br /> rw•m iittr� Bureau of Building Water System <br /> �, SANITARY PERMIT APPLICATION 201E Washington Ave. <br /> In accord with ILHR 83 05,W is.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 8 112 x 11 inches in size. ic- <br /> AQ <br /> • See reverse side for instructions for completing this application Stat Sanitary p mit Numbe <br /> The information you provide may be used by other government agency programs ❑Check it revi on to previous application <br /> lPnvacy Law,s. 15.04(1)(m)l. State Plan I .Number <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION <br /> Prop y Owner Name n Property Location tv <br /> Y r U s w 1/4 A/,6 1/4,5 3,1 T /cl ,N, RI6 R(or)W <br /> PropertyO net's Mailing Ad ess Lot Number Block Number <br /> City,State Zip Code Phone Number Subdivision Nam rCSM Numbe <br /> -4 ut e, A_ s- lir )VU-.216-2- e <br /> II. TYPE OF BUILDING: (check one) ❑ State Owned ❑ Lit <br /> eage Nearest Road <br /> Public 1 or 2 FamilyDwelling- No. of bedrooms C] vii Town of /� N �i N e 4 111.1 <br /> III. BUILDING USE: (If building type is public,check all that apply) Parcel TaxNumber(s) /� <br /> 1 ❑ Apartment/Condo 6 Z ID — 9aor 6 2 j0 0 <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: ipecify <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. ❑ Reconnectior 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 M Seepage Bed 21 E]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 7 <br /> 2. Absorp.Area 3. Absorp.Area 4. Loading Rate 5. Perc. Rate 6. System Elev. 7. Final Grade <br /> CS O Req cuiirred (sq. ft.) Proposed(sq.ft.) (Gals/day/sq.ft.) (Min./inch) Elevation <br /> 1 zo Id' c^ y3d. .7 . 7 1 ,9,77 Feet /6.2.03Feet <br /> TANKCa aclt <br /> VII. INFORMATION ingallons Total #Of Manufacturer's Name Prefab doe_ Steel Fiber- plastic Exper <br /> New Exi Stin Gallons Tanks Concrete stC ed glass App. <br /> Tanks Tanks �e1- <br /> Septic Tank or Holding Tank W 07 ® El ❑ ❑ ❑ ❑ <br /> Lift Pump Tank/Siphon Chamber ❑ I El ❑ ❑ ❑ ❑ <br /> VIII. RESPONSIBILITY STATEMENT <br /> I,the undersigned,assume responsibility for installation of the onsite sewage system shown ot I the attached plans. <br /> Plumber's Nafe: Print) Plumber's Si n ture. oSta s) /MPRSWNo.: usiness Phone Number: <br /> (Print) <br /> o-V-6 lin g V7.2 3 S - <br /> Plumber's Ad f <br /> ss(Stree City,State,Zip Code): _ <br /> I/ t dc �L)r <br /> IX. COUNTY/ DEPARTMENT USE ONLY <br /> Disapproved Sanitary Per(git Fee (Indudes Groundwater ate slue Issuin A tSi atur ( o t mps) <br /> KQ roved W age reef <br /> V�pp ❑Owner Given Initial '--bUC� � i <br /> Adverse Determination <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> s111)-4398(N.05/94) DISTRIBUTION. Original o>(nurdy,One urpy to: S+letyBRullJinga nim;ion,Owneq Plumtx <br />