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Safety and Build ivision <br /> E) 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 01 <br /> than 8 112 x 11 inches in size. ��Uk'N� 6 <br /> • See reverse side for instructions for completing this application State Sanitary <br /> Permit Number <br /> The information you provide may be used b other government agency programs (/� nt �O <br /> y p y y 9 9 y p 9 ❑Check revision to previous application <br /> lPrivacy Law,s. 15.04(1)(m)i. State Plan I_D.N pir <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION I <br /> Propert Owner Name Propert Lo ation <br /> E J5n f/FJ<Z CSL 1IA!;' [�1/4,S JCr T X10 ,N, RI E(or <br /> Propert Owner's Mailing Address - Lot Number Block Number <br /> tC ��'L . - <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> &O&YVilghlAif )WA) 1 55-347 ((v/2) y &559 oRlLlt-1`- Stb�c. <br /> II. TYPE OF BUILDING: (check one) E] State Owned El City Nearest Road <br /> ❑ Public 1 or 2 Famil Dwellin No. of bedrooms ❑ rowan of �fllG� � L�t'c'y+�57Z�190� <br /> 111. BUILDING USE: (If building type is public,check allthatapply) Parcel TaxNumber(s) <br /> 1 ❑ Apartment/Condo <br /> D 2-0 - 4Q� <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.Aew 2. E] Replacement 3_ El Replacementof 4. E] Reconnection of 5. E3 Repair of an <br /> ystem System Tank Only Existing System Existing System <br /> ----------------------------------------------------------------------------------------------- <br /> B) ❑ A Sanitary Permit was previously issued. Permit Number Date Issued <br /> V. TYPE OF SYSTEM: (Check only one) <br /> NonPressurizedDistribution Pressurized Distribution Experimental Other <br /> 11Seepage Bed 21 E]Mound 30 E]Specify Type 41 ❑Holding Tank <br /> 12 eepage 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. 7Final Grade <br /> �day/sq. <br /> Required sq. ft.) Proposed(sq.ft.) (Galft.) (Min./inch) Eieva ions <br /> Feet Ei Feet <br /> TANK Capacity <br /> VII. INFORMATION in gallons Total #of Manufacturer's Name Prefab. conFiber-plastic Exper <br /> New Existin Gallons Tanks concrete strutted- steel glass App. <br /> Tanks Tanks �� 1{ <br /> Septic Tank or Holding Tank 7s75-o El El EJ El ❑ <br /> Lift Pump Tank/Siphon Chamber ❑ ❑ ❑ ❑ ❑ ❑ <br /> VI11. RESPONSIBILITY STATEMENT <br /> I,the undersigned,assume responsibility for installation of the onsite sewage system shown on the attached plans. <br /> P er's Name:(Print) [=Ze�: �o s) MP/MPRSW No.. Business Phone Number: <br /> Plumber's Address(Street,City,State,Zip Code): <br /> `7 3 3s Q4Aa-- bot n <br /> IX. COUNTY/ DEPARTMENT USE ONLY <br /> ❑Disapproved Sanitar PermltFe (Indude,croundweter atelssue Issuing A a ign re mps) <br /> Approved ❑ 74 surcnerge ree) <br /> Owner Given Initial 3 <br /> Adverse Determination <br /> X. CONDITIONS OF APPROVAL/REASONS FIDR DISAPPROVAL: <br /> SND-6398(k 05194) mSTBIBUTION: Onginol to(nunly.One copy To: Safety&Buildings Div,ion,Owner,PlumWr <br />