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Lsb1 <br /> ^�■..,■4■^ Safety and Buildings Division <br /> vY�!�A•• SANITARY PERMIT APPLICATION Bureau of Building Water System, <br /> In accord with(LHR 83.05,Wis-Adm.Code 201 E Washington Ave. <br /> 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. ,L,L <R03CP0 <br /> • See reverse side for instructions for completing this application State Sanitary PPeQermit Numbe <br /> The information you provide may be used by other government agency programs 98 o�"" <br /> (Privacy Law,s. 15.04(1)(m)]. ❑Chec if revision to previous application <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION State Plan I.D<Number nJu <br /> Pr ope rty Owner Name c./ ��� �a%ot <br /> Property Location <br /> /ro CJ y411/4 .V(,,J1/4,S 90 TX? , N, R /5-1(or) <br /> Property Owner's Mailing Address <br /> 6 L�-�I� Block Number <br /> City,State r Z�ode Phone Number Subdiv sionNamme or CSM Number <br /> )�Y9 aY�i <br /> II. TYPE OF BUILDING: (check one) ❑ State Owned ❑ City Nearest Road <br /> Public 1 or 2 FamilyDwellin - No. of bedrooms o� E] Village 4 <br /> Town OF A( 4 P_ enr A J, X <br /> III. BUILDING USE: (If building type ispublic,checkallthatapply) Parcel TaxNumber(s) <br /> 14j( ,p;Z 3 o <br /> 1 ❑ Apartment/Condo and <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 E] Other: specify <br /> IV. TYPE OF PERMIT: (Check only one box on line A. Check box on line B, if applicable) <br /> A) 1. R New 2 ❑ Replacement 3. ❑ Replacement of 4. Reconnection of Repair of an <br /> ystem System Tank Only ❑ Existin S stem 5 ❑ P <br /> ----- ----------------------------------------------------------Existinq Svstem <br /> ❑ 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 210ound 30❑Specify Type 41 <br /> 12 Seepage Trench ❑Holding Tank <br /> ❑ 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 /> 5,�^o Required(sq. ft) Pro osed(sq. ft.) (Gals/day/sq ft.) (Min./inch) Elevation <br /> 7,� :7 >` ��� feet /off Feet <br /> VII. TANK Capacity <br /> INFORMATION in gallons Total #of Prefab Site <br /> New Existin Gallons Tanks Manufacturer's Name Concrete Con- Steel Fiber- plastic ExPer <br /> Tanks Tanks <br /> strutted glass App_ <br /> Septic Tank or Holding Tank e,90 /0D0 ❑ ❑ ❑ <br /> l ift Pump Tank/Siphon Chamber p00 Z76-0 7 ❑ <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 NNc/�pme:(PP t)) Plumber's Signature: No Stamps) MP/MMPPRSW N/o/' BusirneesssPPhone NuuJmb^e�r: �7� <br /> i r �. Y 6 may, lwi��/Gce"G�_ ®7 `�/ tom/ !�'/�C JV ! <br /> Plumber's Address(Street,City,State,Zip Sode): <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑Disapproved Sanitary Permit Fee (IndudesGroundwater ate l9sue IssuingA a Sign tire amps) <br /> Vp proved ❑Owner Given Initial © rr1 urch�r9etee /a q <br /> Adverse Determination /25� J <br /> X. CONDITIONS OF APPROVAL/REAS NS FOR DISAPPROVAL: <br /> SRU-6398(R.OS/94) DISrRIBUTIUN: Ori incl tJ Cnunt On <br /> 9 Y. a U,Py 7a: Sufety S fluilJinye nimvon,rlwner,%um Frer <br />