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E <br /> Saand Buil ings Division <br /> ■■r'i 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 <br /> than 81/2 x 11 inches in size. <br /> • See reverse side for instructions for completing this application State sans Ly Permit Number <br /> Clcret vJ W`FP <br /> The information you provide may be used by other government agency programs ❑check it ievision to previous application <br /> [Privacy Law,s. 15.04(i)(m)I. <br /> State Plan D.Number <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION <br /> Property Owner Name Property Location <br /> L 1/4 1/4,S QHS 0 ,N, R IS E (or(W) <br /> Property Owper's Mailing Address Lot Nu ber Block Number <br /> 2.19 S n LK. ED. <br /> Gy,State Zip ode Phone Number Subdivision Name or CSM Numbe <br /> s?ZR s �- 8` 92 <br /> [I. TYPE OF UILDING: (check one) ❑ State Owned ❑ sty Nearest Road <br /> Village �e- <br /> ❑ Public 1 or 2 FamilyDwelling- No. of bedrooms Z Town Or-v Ck SANO LK- RP - <br /> 111. BUILDING USE: (If building type is public,check all that apply) arcel Tax <br /> Number(s) <br /> 1 ❑ Apartment/Condo 1 0)), <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 ❑ Servi eStation/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. ❑ New 2,RReplacement 3. ❑ Replacement of q ❑ Reconnects on of 5. ❑ Repair of an <br /> System System Tank Only Existing Sy tem -- Existing System <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 /> 11 N 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 Per2. Absorp_Area 3. Absorp.Area 4. Loading Rate 5. Perc. Rate . System Elev. 7. Final Grade <br /> Re fired (sq. ft-) Proposed (sq. ft.) (Gals/day/sq. ft.) (Min./inch) Elevation <br /> 300Day Zq 1 1437- •7 f— S• Z Feet /El7.7 Feet <br /> TANK Ca acrt <br /> VII. INFORMATION in gallons Total # of MPrefab SI e- Fiber- plastic Exper <br /> New Existin Gallons Tanks Manufacturer's Name Concrete Steel glass App <br /> st ucted <br /> Tanks Tanks <br /> Septic Tank or Holding Tank 0 I f]y�/ ❑ ❑ ❑ ❑ ❑ <br /> l ift Pump Tank/Siphon ChamberbbG 6 1 I AW ❑ ❑ ❑ ❑ ❑ <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) Plum ber'j Signature:( o St ps) MP/MPRSW No.: Business Phone Number: <br /> IC p l 3qn 'IIS- 56-qtV <br /> Plumber's Address(Street,City,Sta Zip Code): 6�QQ // p <br /> GP G W1, B <br /> IX. COUNTY/ DEPARTMENT USE ONLY <br /> ❑Disapproved Sanitary Permit Fee (Indudes Groundwater ateIssue Iss mg Agent Signature NoS amps) <br /> kApproved ❑Owner Given Initial �} SR hzrgefee) <br /> Adverse Determination `+� 1c )i �C� <br /> X. CONDITIONS OF APPROVAL/ REASONS FOR DISAPPROVAL: <br /> SrDb398(1.05194) DISTRIBUTION. Original l0(uunly,Of—U, ,Tn: S.duty B Rudkin,Dlmoon,nwner,Plu 11K, <br />