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Safety and Buildings ;vision <br /> SANITARY PERMIT APPLICATION Bureau of But Water System <br /> 201 E-Washington Ave. <br /> ' L• 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 a2,06 <br /> 3 <br /> than 8 1/2 x 11 inches in size. 5 ate Sanitary Permit Number(� <br /> • See reverse side for instructions for completing this application (/Q <br /> The information you provide may be used by other government agency programs ❑ <br /> Check i s Q rt viuu�lication <br /> (Privacy Law,s. 15.04(1)(m)I. State Plan I.D.Number, ',4 <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMA peONrLy ocation //'J�/►7�'� <br /> Property Owner Name /[3 Cie r /arye 1/4 1/4,S T 4Q N,R b E(or)W <br /> "( L ow (.�/Q" Lot Number Block Number <br /> Property Owner's ailingAudress 0p1,.�- t �( <br /> 1 ftpU RD - f J� oma <br /> City,State Zip Code 42 31j� <br /> 3o Phone Number Subdivi ion Name or umber <br /> 1(1715) <br /> 'El' City Nearest Road <br /> II. TYPE OF ILDING: (check one) ❑ State Owned ❑ Village -t <br /> ❑ Public 1 or 2 Family Dwellin - No. of bedrooms Town OF <br /> Parcel Tax Number(s) <br /> III. BUILDING USE: (If building type is public,check all that apply) Q 70 <br /> 0 <br /> 1 ❑ Apartment/Condo LN LO,v� <br /> Medical Facility/Nursing Home 1LEt or Recreational Facility <br /> 2 F1 Assembly Hall 6 ❑ y 1rant/Bar/Dining <br /> 3 Campground 7 F1 Merchandise:Sales/Repairs <br /> Mobile Home Park 1e Station/Car Wash <br /> 4 ❑ Church/School $ ❑ : specify <br /> office/Factor <br /> 5 ❑ Hotel/Motel 9 ❑ y <br /> IV. TYPE OF PERMIT: (Check only one box on line A. Check box on line B, if applicable) Re air of an <br /> ❑ New 2. Replacement 3. ❑ Replacement of 4_ ❑ Reconnection of 5. ❑ p . <br /> A) 1. Tank onlyExisting System- - _ Existing System <br /> System System -------------------- -------------- <br /> -------------- <br /> Date Issued <br /> B) ❑ A Sanitary Permit was previously issued. Permit Number <br /> V. TYPE OF SYSTEM: (Check only one) Other <br /> Non Pressurized Distribution Pressurized Distribution Experimental <br /> 1 1Seepage Bed 21 ❑Mound 30 E]Specify Type 41 El Holding Tank <br /> 12 Seepage Trench 22❑ 42❑Pit Privy In-Ground Pressure 43 E]Vault Privy <br /> 13❑Seepage Pit <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. Elevlati I Grade <br /> Required(sq.ft.) Proposed(sq.ft.) (Gals/day/sq.ft.) (Min./inch) Q 9 <br /> 3OO Z -� -JS-q Feet $.`I Feet <br /> VII. TANK Capacity Total #of Prefab Site Fiber- plastic Exper <br /> INFORMATION a gallons Gallons Tanks Manufacturer's Name Concrete Con- Steel glass App <br /> New Existin strutted <br /> Tanks Tanks I SEl n El 11 <br /> Septic Tank or Holding Tank ✓ El n El 1 <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:(No Stamps) <br /> MP/MPRSW No : Business Phone Number: <br /> IC 44 A 1212 0 Sjuj Aez� <br /> Pumber'sAddress(Stree ty,State,_ZipCode { <br /> 17:1 X <br /> IX. COUNTY/ DEPAR MENT USE ONLY <br /> Sanitary Permi F e (InclutlesGroundwa[er atelssu/ Issuing Agent ignatur o5tamps) <br /> y <br /> ❑Disapproved / Surchargeree) <br /> �pproved ❑Owner Given Initial <br /> Adverse Determination <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBO-6398(R.05/94) <br /> DISI NI BUTION'. original to 4nur,l y,one copy To. Solely 8 Buil&rigs Divr.ion,Owner,Plumber <br />