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�ii.. r•+i � / <br /> SANITARY PERMIT APPLICATION Bureauo Building�ystem, <br /> In accord with ILHR 83.05,Wis.Adm,Code 201 E Washington Ave. <br /> P.O.Box 7969 <br /> • Attach complete plans(to the count co Madison,WI 53707-7969 <br /> than 8 1/2 x 11 inches in size. Y PY only)for the system,on paper not less FStaiteSainitar <br /> • See reverse side for instructions for completing this application Per it Nuumb r O'j <br /> The information you provide may be used by other government agency programs ��1, v/ (pg(PrivacyLaw,s. 75.04(1)(m)lCheck if revision to previous application <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL IN RMATION State Plan I.D Nur�be= 03&0 <br /> Pr rtyOw rNam Gy// <br /> r <br /> Property Location <br /> ropertyOwner'5 Mallinq Addr s 1/4 1/4,S T 440 ,N, R/le 29m)CJI/ <br /> Lo umber Block Number <br /> ity,State Zi Code <br /> de Phone Number Sub -Sion me or CSM Number P / <br /> . TYPE OF BUILDING: (check one) ❑ State Owned ❑ aty <br /> ❑ Public 1 or 2 Famil Dwellin - No. of bedrooms village Ne !�s Road <br /> Hl. BUILDING USE: (If buildingtype is public.check all thata I Parcel Tax Number(s)Town OF G <br /> YP P apply) <br /> 1 ❑ Apartment/Condo (�� � y(/�S <br /> 2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursin Home <br /> 3 E] 7 ❑ Merchandise: g 10 ❑ Outdoor Recreational sales/Repairs 11 <br /> 4 E]E] <br /> 8 El MobileHomePark El Restaurant/Bar/Dining Facility <br /> 5 E] Hotel/Motel 9 El Office/Factory 13 12 ED Service Station/Car Wash <br /> IV. TYPE OF PERMIT: (Check only one box online A. Check box online B, if applicable)Other: specify <br /> A) 1. ❑ New 2 to Replacement 3. ❑ Replacement of q Reconnection of <br /> System 'IR Tank-Only S. ❑ Repair of System-______y ___System ______________ � Existin S stem <br /> B) ----------------------9-y-------------Existing System <br /> ❑ A Sanitary Permit was previously issued. Permit Number <br /> V. TYPE OF SYSTEM: (Check only one) Date Issued <br /> Non Pressurized Distribution Pressurized Distribution <br /> 11 ❑Seepage Bed Experimental Other <br /> 12 El Seepage Trench 21 El Mound 22 E]In-Ground Press30 F]Specify Type 41 Holding Tank <br /> Pressure <br /> 13 E]Seepage Pit 42 Pit Privy <br /> 14❑System-In-Fill 43❑Vault Privy <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 Grar <br /> Required(sq.ft.) Proposed(sq. ft.) (Gals/day/sq. ft.) (Min./inch) _ <br /> _ Elevation <br /> VII. TANK Capacity Feet Fee <br /> INFORMATION In gallons Total #of <br /> Gallons Tanks Manufacturer's Name Prefab Site Fiber- <br /> Nnk Existin Concrete Con- Steel Plastic Exper. <br /> Tanks Tanks strutted glass App <br /> Septic Tank lding Tan <br /> ['ft Pump Tank/Siphon Chamber u � 7y <br /> ❑ ❑ ❑ ❑ ❑ <br /> VIII. RESPONSIBILITY STATEMENT -LL <br /> ❑ 01 ❑ ❑ ❑ ❑ <br /> I,the undersigned,assume responsibility for installation of the onsite sewage system shown on the attached plans. <br /> PI m er's Name:(Print) Plumber's ignature:(N Sta <br /> ��� �� ` Ps) MP/MPRSW No.: Business Phone Nu/tuber: <br /> Plumber's Address(Street,City,State�p Code). A077 �/ �Ea g jZ���yC <br /> IX. COUNTY/ DEPARTMENT USE ONLY45 <br /> E]Disapproved Sanitary permit Fe fnrivaesGroundwater ate issue <br /> proved ❑Owner Given Initial �� Q{1 Surrhwge Fee) �O Issuing Agent 5i nature(No St ) <br /> 0 Adverse Determination 1 ,/�r. l /q7 <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> 5HD-6398(R.OS194) <br /> DISTRIRUTION. original t^Cour.ly,One copy To: 50ely&fluildi^gs Divrion,Owner,Plumber <br />