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Safety and Buildings Division <br /> Bureau of Building Water Systems <br /> SANITARY PERMIT APPLICATION 201 E.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 8112 x 11 inches in size. t '� <br /> State Sanitary Permit Number <br /> • See reverse side for instructions for completing this application <br /> The information you provide may be used by other government agency programs ❑Check it revision to previous application <br /> (Privacy Law,s. 15.04(1)(m)l. StaVlan I.D.Number <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION g� _aZ3oo <br /> Proper ANS /Loca <br /> 14,5 9 T3� ,N, �5 � <br /> Pro a Owner ame R W <br /> VC Lot Numb`r,3 Block Number <br /> Prop rt Owner's Mailing Address St <br /> W e "(J �n <br /> city,St <br /> v Zip Code Phone Number Subdivisic" ame or CSMNu�n bar 1 <br /> I VVt I,, SSto ] t(afZ)eA7-b�o- �COW� Hdd r+ts . <br /> y Nearest Road <br /> II. TY E F BUILDING: (check one) E] State Owned o v liage ) � }14,rt d <br /> Public 1 or 2 Famil Dwelling-No.of bedrooms 3 Town OFHI `�Z{�� QF <br /> Parcel Tax Number(,) <br /> III. BUILDING USE: (If building type is public,check allthatapply) ,j((� <br /> 1 ❑ <br /> Apartment/Condo <br /> ©l�{- - D 3oc <br /> 2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility <br /> 3 ❑ Campground 7 ❑ Merchandise: Sales/Repairs p 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 /> Replacement 3. Replacement of 4. ❑ Reconnection of 5, ❑ Repair of an <br /> '°`) 1_ ❑ New 2. p ❑ TankOnl _ExistingSystem -_______ Existing_System <br /> System System --------------------Y------------ <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 UJ 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. Loadingtft.) (Min./inch) <br /> rc. Rate 6. System Elev. 7. Final Grade <br /> Re�qu;`3(sq. ft.) Proposed .ft.) (Gals/day/sq. _ Egle�vyation <br /> 7 'C 3, Z-' Feet [O Feet <br /> VII. TANK CapacltYPrefab site pngallons Total #OfManufactConcrete Con- Steel g ass Plastic EApvrINFORMATION New Existin Gallons Tanks structedTanks Tanksnk K V O OEl El Q El <br /> te. LR Q <br /> Lift Pump Tank/smi,,n Chamber Li ❑ El <br /> VIII. RESPONSIBILITY STATEMENT <br /> I*Ibe�r� <br /> thundersigned,assume responsibi ty for installation of the onsite sewage system shown on the attached plans. <br /> Name: t) Plu ber's Si natur ( tamps) MP/MPRSW No.: Business Phone Number. <br /> VK� s? is t 6 <br /> ddre (Stree2, y,State,Zi e): �IX. COUNTY/ DEPA TMENT USE ONLY (C1 Q J C <br /> Disapproved Sanitary Permit Fee tmouaes Grovnewater ateyy55ue Issuing Agen ig ure( tamps) <br /> PAPP ❑ PP 96 $urchargeFee) <br /> roved Owner Given Initial ) VMS (P`I ` lN1lrl� <br /> Adverse Determination <br /> X. CONDITIONS OF APPROVAL/ REASONS FOR DISAPPROVAL, <br /> cun.aaox Ix nsrv41 OISTRIaUT10N: Original to CouNy,One ropy To: ,atelY 8 auilainga Division,Owneq Plumber <br />