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on (-0)7w, <br /> Safety and Buildings Division <br /> i:,1L:;FC SANITARY PERMIT APPLICATION Bureau of Building Water System <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 <br /> than 8 112 x 11 inches in size. <br /> • See reverse side for instructions for completing this application State Sanitary <br /> //Permit Nummber <br /> The information you provide may be used by other government agency programs ElC k V viL Ilfe��tous application <br /> [Privacy Laws- 15.04(i)(m)1, <br /> State Plan LD.Number <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION <br /> Property Owner Name N grorty kocation <br /> DAK Mt <br /> nl W 1 TAT S T ,N, R E or <br /> PropertOwner' L <br /> s Mailing Address qq�� Lot Number <br /> De <br /> City, tate 2ipC de Phone Number Subdivision Name or CSM Number <br /> �0MER 61 oz5 ( s )z4 - 53 <br /> II. TYPE OF BUILDING: (check one) ❑ State OwnedII Nearest Road <br /> Public X1 1 or 2 Family Dwell in - No. of bedrooms Z- a iora9 OF u�L�LAJ ( C$I200K <br /> III. BUILDING USE: (If building type is public,check all that apply) Parcel TaxNumbbeer(s) �1 <br /> 1 ❑ Apartment/Condo �)fx" '���� —D` - <br /> 2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility <br /> 3 ❑ Campground 7 ❑ Merchandise: Sales/Repairs 11 ❑ Restaurant/Bar/Dining <br /> 4 ❑ Church/School 8 ❑ Mobile Home Park 12 ❑ Service Station/Car Wash <br /> 5 ❑ Hotel/Motel 9 ❑ Office/Factory 13 ❑ Other: specify <br /> IV. TYPE OF PERMIT: (Check only one box on line A. Check box on line B, if applicable) <br /> A) 1. {(g�New 2. Replacement 3. E] Replacement of 4. E] Reconnection of 5. E] Repair of an <br /> System System ____ Tank Only Existing System Existing System <br /> B) ❑ A Sanitary Permit was previously issued. Permit Number Date Issued <br /> V. TYPE OF SYSTEM: (Check only one) <br /> Non-Pressurized Distribution Pressurized Distribution Experimental Other <br /> 1 1$[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 /> 2. Absorp.Area 3. Absorp.Area 4. Loading Rate 5. Perc. Rate 6. System Elev. 7. Final Grade <br /> Required (sq.ft.) Proposed (sq. ft.) (Gals/day/sq. ft.) (Min./inch) Elevation <br /> 3007PI 32 p 7 .-✓� IS .125' Feet $ .$' Feet <br /> 1. Gallons Per Day <br /> Ca acrt <br /> VII. TANK n gallons Gallltal #oflons Tanks Concrete Site Steel Fiber- <br /> INFORMATION Plastic Aper <br /> Manufacturer's Name con- <br /> New Existin strutted <br /> Tanks Tanks <br /> Septic Tank or Holding Tank H C ❑ ❑ p ❑ ❑ <br /> Lift Pump Tank/Siphon Chamber, ❑ ❑ ❑ ❑ ❑ ❑ <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 IN amps) MP/MPRSW No.: Business Phone Number: <br /> g!C-I9IqJZQ 0010,41J4IS- - ISI <br /> Plumber's Address( trees,City,St e,Zip Code): <br /> WI <br /> IX. COUNTY/ DEPARTMENT USE ONLY <br /> E]Disapproved Sanitary Permit Fee lindudes Groundwater Date Issued Issuing Agent Clgnat eIN ps) <br /> pproved ❑Owner Given Initial (x urchargeeee) ��� <br /> Adverse Determination I (/. ;d_ 4 <br /> X. CONDITIONS OF APPROVAL/REASONS FOR APPROVAL: <br /> SUD-6398(R.05M) DISTRIBUTION: Originalto Courcy,One copy To: Sulety&Ruildingt Division,Owner,Plumber <br />