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jj Bn Car2�, <br /> Safety and Buildings Division <br /> SANITARY PERMIT APPLICATION Bureau of Building Water System. <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 8 112 x 11 inches in size. rnetk:-_-- <br /> • See reverse side for instructions forcompleting thisapplication state anitar P mltNumberQ5s7.1 <br /> ((&I, ;t <br /> The information you provide may be used by other government agency programs ❑Check it re ilio o previous application <br /> IPnvacy Law,s. 15.04(1)(m)1. <br /> State Plan I. .Number <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION <br /> Property Owner Name Property Location <br /> Rr n? -50,t) t Et i4 NW 1/4,5jk I T c ,N, R /.S'E(or)& <br /> Pro{plerty Owner's Mailing Address Lot Number lock Number <br /> / (, O.� Y5— <br /> City, <br /> SCity,State Zip Code Phone Number Subdivision Name or CSM Num ber j <br /> /fertel Gc.J-Fi–yS'ys ( <br /> 11. TYPE (5—FBUILDING: (check one) ❑ State Owned ❑ GL Nearest Road <br /> ❑ village S ti p / /f <br /> ❑ Public 1 or 2 FamilyDwelling- No. of bedrooms Town OF Com, /I d iT <br /> 111. BUILDING USE: (If building type is public,check all that apply) Parcel TaxNumber(s) �/{,` <br /> 1 ❑ Apartment/Condo ' �— )—"-'v <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. ❑ 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 N Seepage Bed 21 ❑Mound 30❑Specify Type 41 ❑ Holding Tank <br /> 12❑Seepage Trench 22❑In-Ground Pressure 42 p Pit Privy <br /> 13❑Seepage Pit 43❑Vault Privy <br /> 14❑System-In-Fill <br /> VI. ABSORPTION SYSTEM INFORMATION: <br /> 1_ Gallons PerDay 2. Absorp_Area 3. Absorp.Area 4. Loading Rate 5. Perc. Rate 6. System Elev. 7. Final Grade <br /> y� Required(sq. ft.) Proposed (sq. ft.) (Gals/day/sq. ft.) (Min./inch) Elevation <br /> cFeet yY• Y Feet <br /> Ca aclt <br /> VII. TANK in gallons Total <br /> #ofTanks Concrete Si a Steel Fiber- Exper <br /> INFORMATION Manufacturer's Name c n- plastic p <br /> New Existingstrutted <br /> glass App. <br /> Tanks Tanks (� // <br /> Septic Tank or L_.�R*_ ooe) 100c) /�/TLl� NEl n ❑ <br /> Lift Pump Tank/Siphon Chamber <br /> Vill. RESPONSIBILITY STATEMENT <br /> I,the undersigned,assume responsibility for installation of the onsite sewage system shown o i the attached plans. <br /> Plumber's Name:(Print) Plumber's Signature. (No Stamps) MPRSW No.: Business Phone Number: <br /> .7 1e19- Ae <br /> PIu tier's Address(Street,City,State,Zip Code): <br /> IX. )COUNTY/ DEPARTMENT USE ONLY <br /> ❑Disapproved Sanitary Permit Fee Ilnduden Grovndweter Ciatelssued Iss g gent gnature(No Stamps) <br /> Approved Owner Given Initial Surrhar9e«eeI <br /> 1 2�J <br /> Adverse Determination <br /> X. C NDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SND b398(II.05194) DISTRIBUTION OnglnnitoCoonp,One<upy To: &RulLlln,Di-.,I)—,Pfo.b <br />