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E <br /> Safety and Buildings Division <br /> ;; SANITARY PERMIT APPLICATION <br /> Bureau of Building Water System. <br /> 207 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. 1 I' <br /> • See reverse side for instructions for completing this application St a esanit Perm tNumbera SC�(�(1C) <br /> igao n b <br /> The information you provide maybe used by other government agency programs E]Check it rev Ion to previous application <br /> [Privacy Law,s. 15.04(1)(m)I- State Plan LD.Number <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION <br /> Property Owner Nam Property Location <br /> J')o44 <br /> v4 v4,5 % T ,N, R E (or W <br /> Property Owner's Mailing Address Lot Number Block Number <br /> 02$ LEn! W 1 LI) 'je L►J <br /> City,State Zip Code Phone Number Subdivisio Name orC MNumber <br /> I,0C,M 4 a •Mj 3'S 3 61 >885-d ism I - 9103 <br /> II. TYPE BUIL ING: (check one) ❑ State Owned ❑ aty Nearest Road <br /> ❑ Village <br /> ❑ Public 1 or 2 FamilyDwelling- No. of bedrooms Town OF LL D_ <br /> ;II. BUILDING USE: (If building type is public,check allthatapply) Parcel TaxNumber(s) / <br /> 1 ❑ Apartment/Condo I <br /> c��� <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) 1 131 New 2. ❑ Replacement 3_ ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an <br /> System System Tank Only Existing5ystem 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�dSeepage 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 S. Perc. Rate 6. System Elev. 7. Final Grade <br /> 4eT Req it d (sq. ft.) Proposed (sq. ft.) (Gals/day/sq.ft.) (Min./inch) ,( Elevation <br /> jD rp 3 8 .7 �I • 1 Feet (.. (p Feet <br /> Ca acrt <br /> VII. TANK in gallons Total #of Prefab srce Fiber- plastic Exper <br /> INFORMATION New Existin Gallons Tanks Manufacturer's Name Concrete st uucted steel glass App. <br /> Tanks Tanks <br /> Septic Tank or Holding Tank 000 AvJ (�� ❑ ❑ ❑ ❑ ❑ <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 /> Plumbejs Name (Print Plumber's ignature:( oSt mps) MP/MPRSW No.: Business Phone Numb r. <br /> /n/S 3 u lS - IS7 <br /> Plumbei s Address(Stree ,City,State,Zip Code): <br /> 2-1-7&0 w 35 Will- SVV3 <br /> IXI COUNTY/ DEPARTMENT USE ONLY <br /> ❑Disapproved Sanitary Permit Fee (InuudeeGrovnawater ate Issued ss ng gent Sig ure(No Stamps) <br /> roved ge reel <br /> p ❑Owner Given Initial <br /> p Adverse Determination <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SHD 1,398(IT 05/94) DISTRIBUTION. Original ro Cmue y.One<opy Tu: SeD,"a BuilJings Dlvuion,Owner,Rlumper <br />