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its <br /> Safety and Buildings Division <br /> SANITARY PERMIT APPLICATION BureauoiBu,IdingWaterSystems <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 8 1/2 x 11 inches in size. <br /> • See reverse side for instructions for completing this application State Sanitary Permit Number <br /> The information you provide may be used by other government agency programs a 81r7lq <br /> (Privacy Law,s. 15 04(1)(m)] []Check it revision to previous application <br /> State Plan I.D.Number <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION I � <br /> Property Owner NamePropert Location <br /> 1/4 t1'4 S T I ,N, R ? E(or W <br /> Property Owner's Mailing Address Lot Number Block Number <br /> ZD T-Ro o ST- <br /> City,State -r Zip Cod Phone Number <„t.a:..:�^-xLaa1Q .,ZSA4. -r <br /> IV. Z( Z ( ) 17P Acf,6� <br /> II. YPE F ILDING: (check one) ❑ State Owned ❑ ity Nearest Road �r- <br /> � <br /> Public 1 or 2 FamilyDwellingL El- No. of bedrooms Village ��/ 1 <br /> own OF .SuiW ST <br /> III. BUILDING USE: (If buildingtypelspublic,checkallthatapply) Parcel TaxNumber(s) /,, �-p� <br /> 1 E] Apartment/Condo —5� _ - 0l -)co <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. X New 2. ❑ Replacement 3- ❑ Replacement of q ❑ Reconnection of 5. ❑ Repair of an <br /> ------System System Tank Only Existing System Existing System <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`4 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. Loading Rate 5. Perc. Rate 6. System Elev. 7. Final Grade <br /> Re i red(sq.ft.) Propped(sq. ft.) (Gals/day/sq. ft.) Min./inch) Elevation <br /> 300q// <br /> Al. TANK Capaoty t'F Feet 0 Feet <br /> INFORMATION in gallons Total #of Manufacturer' Prefab. Site Fiber- plastic Exper <br /> New Existings Name Gallons Tanks concrete con- Steel glass App. <br /> Tanks Tanks strutted <br /> Septic Tank or Holding Tank 1001 — 'SW AVJ ® ❑ 11 El <br /> Lift Pump Tank/Siphon Chamber I 1 11 ❑ Ej <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:(Pant) Plumber's Signatu e: oStamps) MP/MPRSW No.: Business Phone Number: <br /> )c n! d866- <br /> PIu tier's Address(Street,City,St te,Zip Code): <br /> 'ZTX0 Hwce,52,f W I- -5`4893 <br /> IX. COUNTY/ DEPARTMENT USE ONLY <br /> ❑Disapproved Sanitary Permit Fee pncbde,GmunEwater ate sue Issuing ntS at re( amps) <br /> roved h4rge Fee) /s <br /> PP ❑Owner Given ) CQ / /p <br /> Adverse Determination /�J / <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(R.05/94) DISTRIBUTION: Original to County,One copy To: Safety&Buildings Division,Owner,Plumber <br />