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Safety and Buildings Division <br /> lding Water System <br /> SANITARY PERMIT APPLICATION Bureau of Bur <br /> w .KV�.• 201 E Washington Ave. <br /> V■`�� <br /> In accord with[LHR 83.05,Wis ..Adm.Code P.OBox 7969 <br /> Madison,WI 53707-7969 <br /> • Attach complete plans(to the county copy only)for the system,on paper not less County p i// 2 <br /> than 8 112 x 11 inches in size. TN J <br /> Sta eSanitary Permit Number <br /> • See reverse side for instructions for completing this application 5- Q / 7 <br /> The information you provide may be used by other government agency programs ❑Chec�revisiOn to previous application <br /> [Privacy Law,s. 15.04(1)(m)L State Plan I.D.Number <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION �� <br /> Property Owner Name Property Location <br /> o N M THE 1i4 v4,S IBi 13 T ,N, R '5 E (or) <br /> Property Owner's Mail, gA dress Lot Number Block Number <br /> I6 Z- HI r TO q3 <br /> City,State Zip Code Phone N tuber Subdivision Name or CSM Number 1' <br /> n! 55 ( 12>�3`I l00o E V <br /> II. TYPE F BUILDIN : (check one) ❑ State Owned illy Nearest Road r �/ <br /> ❑ Towne �.PW'G R W� <br /> Public 1 or 2 FamilyDwellin - No.of bedrooms �— Town oF.TR�+1C50h/ <br /> III. BUILDING USE: (if building type is public,check all that apply) Parcel Tax Number(s) <br /> 1 ❑ Apartment/Condo <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 online B, if applicable) <br /> New 2. Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an <br /> A) 1. ❑ ® Existing System _ExistingSystem <br /> System System __________ TankOnly ________ <br /> B) ❑ ASanitaryPermitwaspreviouslyissued. 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 /> 43❑Vault Privy <br /> 13❑Seepage Pit <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- Fiinal Grade <br /> Re wired (sq.ft.) Proposed (sq. ft.) (Gal ay/sq. ft.) (Min./inch) X02 (o <br /> (gym �� 6�$ Feet 05.1 Feet <br /> VII. TANK Ca pa 'tY Site Fiber_ Exper <br /> in gallons Total # of Manufacturer's Name Prefab con- Steel Plastic <br /> INFORMATION New Existin Gallons Tanks Concrete strutted Sass APP. <br /> Tanks Tanks ❑ ❑ ❑ ❑ ❑ <br /> Septic Tank or Holding Tank ❑ <br /> - O ❑ ❑ ❑ ❑ <br /> Lrft Pump Tank/Siphon Chamber <br /> VIII. RESPONSIBILITY STATE ME / 00 <br /> I,the undersigned,assume responsibility for installation of the onsite sewage system shown on the attached plans. <br /> Plum tier's Signature:(No Stamps) MP/MPRSW No.: Business Phone Number: <br /> Plumber's Name:(Print)rtNq o K/ S 1S Sbb- IS <br /> Plu tier's Address(Street,City,State.Zip Code): (. y�p�� <br /> Z-1 160 w 35' V.IEBSt�tt W �7 O <br /> IX. COUNTY/ DEPARTMEN USE ONLY <br /> Disapproved Sanitary Permit Fe p""vdeserovndwaeer ate ,sue Isswng ent Si ature( S mps) <br /> ❑ PP �� surcharge ree) <br /> [Approved <br /> E]Owner Given Initial J <br /> Adverse Determination / <br /> X. CONDITIONS OF APPROVAL/ REASONS FO DISAPPROVAL: <br /> Stlnfi99a(1t.05194) DISTRIBUTION 0ri9i"nl ur Courcy.One u,Py To: 5uo"y&&111dhnp Dlm:ion,Owner,Plumber <br />