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C/,-YL- CI� S ety and Buildings <br /> �.■`nom SANITARY PERMIT APPLICATION Bureau of Building'201 E.Washington <br /> In accord with[LHR 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 3 6 <br /> than 8 1/2 x 11 inches in size. <br /> • See reverse side for instructions for completing this application tate Sanitary P�itNµmb <br /> 0 -75 <br /> The information you provide may be used by other government agency programs ❑Check if revision 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 Name P opertLocation <br /> A 1& 1/4,S T ,N, R 1'4- E(or(9 <br /> Prop rty Own 's Mai ing Address Lot Number Block Number <br /> 244-'' gr <br /> City,State Zi Code Phone Number Subdivision Name or CS Number <br /> M4_ S (612- LU K.E5 WoovS <br /> II. TYPE OF BUILDING: (check one) ❑ State Owned ❑ ity Nearest Road <br /> El Village <br /> Public ❑ 1 or 2 Family Dwelling- No. of bedrooms own OF Cum Ry <br /> II. BUILDING USE: (If building type is public,check all that apply) Parcel TaxNumber(s) <br /> 1 ❑ Apartment/Condo 1 ( S - Z- 200 <br /> 2 F] Assembly Hall 6 E] 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.XReplacement 3_ ❑ Replacement of 4. ❑ 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 (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 RateS. Perc. Rate 6. System Elev. 7. Final Grade <br /> Required (sq. ft.) Proposed(sq.ft.) (Gals/day/sq. ft. (Min./inch) Elevation <br /> iso Z ) Z.50 Feet R - S Feet <br /> VII. TANK Capac Site <br /> In gallons Total #Of Manufacturers Name Prefab. Con- Steel Fiber- LQc <br /> Aper. <br /> INFORMATION Gallons Tanks Concrete glassApp <br /> New Existin structed <br /> Tanks Tanks <br /> Septic Tank or Holding Tank JS L ❑ ❑ ❑ <br /> Lift Pump Tank/Siphon Chamber Q ❑ El Ej El <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 ps) MP/MPRSW No.: Business Phone Number: <br /> S - <br /> Z6 <br /> c P tus AddrreetCity state,Zip Code) <br /> W �Z-r D � <br /> S46 <br /> IX. COUNTY/ DEPARTMENT USE ONLY <br /> ❑Disapproved Sanitary Permit Fe ('ncI°des Gr°°ndwmer ate lsue Li <br /> A ntSi nater tamps) <br /> jIJJ <br /> pproved ❑ Surcharrge t ee) <br /> Owner Given Initial 56 �l <br /> Adverse Determination v ' <br /> X. CONDITIONS OF APPROVAL/ REASONS FOR DISAPPROVAL: <br /> 581-6398(R.W94) DIs T'RIRUTION_ Original to Cnurt y,One ropy To: Salety 8 RuilJings Divnlon,Owner,plwntKr <br />