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c <br /> "�'=i-`a °• Safety and Buildings Division <br /> SANITARY PERMIT APPLICATION Bureau of Building Water Systems <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 8112 x 11 inches in size. I 3 <br /> • See reverse side for instructions for completing this application State Sanitary Permit Number <br /> 3-,;� a3& <br /> The information you provide may be used by other government agency programs ❑Check it revision to previous application <br /> (Privacy Law,s. 15.04(1)(m)I. State Plan I.D.Number <br /> 1. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION <br /> Property Owner Name , Property Location <br /> Ko ���,p� 1/4 1/4,S 18 T 3V ,N, R 14E(orJ© w <br /> Property Owner's Mailing Add Lot Number Block Number <br /> 0 — QAC 19 1 Z <br /> City ate Zip Code Phone Number Subdivision Nime or CSM Number <br /> l viur1l/1 I 5531(o (Ll2 )4z,5- 53 s TtlLOL <br /> II. TYPE OF BUILDING: (check one) ❑ State Owned 0 uty N crest Road <br /> Public 1 or 2 FamilyDwelling- No.of bedrooms � ° vowan OF eLO <br /> III. BUILDING USE: (If building type is public,check all thatapply) Parcel Tax Number(s) <br /> 1 ❑ Apartment/Condo I 00$- DSO- OL q00 <br /> 2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility <br /> 3 ❑ Campground 7 ❑ Merchandise: Sales/Repairs 11 ❑ Restaurant/Bar/Dining <br /> 4 ❑ Church/School 8 ❑ Mobile Home Park 12 ❑ Service Station/Car Wash <br /> 5 ❑ Hotel/Motel 9 ❑ Office/Factory 13 ❑ Other: specify <br /> IV. TYPE OF PERMIT: (Check only one box on line A. Check box on line B, if applicable) <br /> A) 1. New 2. ❑ Replacement 3. ❑ Replacement of 4_ ❑ Reconnection of 5. ❑ Repair of an <br /> System -- System -- - Tank Only---------------Existing System Existing System <br /> B) ❑ A Sanitary Permit was previously issued. Permit Number Date Issued <br /> V. TYPE OF SYSTEM: (Check only one) <br /> Non-Pressurized Distribution Pressurized Distribution Experimental Other <br /> 1 1 O'Seepage Bed 21 ❑Mound 30❑Specify Type 41 ❑Holding Tank <br /> 12❑Seepage Trench 22❑In-Ground Pressure 42❑Pit Privy <br /> 13❑Seepage Pit 43❑Vault Privy <br /> 14❑System-In-Fill <br /> VI. ABSORPTION SYSTEM INFORMATION: <br /> 1. Gallons Per Day 2. Absorp.Area 3. Absorp.Area 4. Loading Rate 5. Perc. Rate 6. System Elev. 7. Final Grade <br /> Required(sq.ft.) Proposed(sq.ft.) (Gals/day/sq. ft.) (Min./inch) Elevation <br /> f4�10 1 4 013 G i h �y Feet 96. F4- Feet <br /> Capcut . <br /> VII. TANK in allons Total #of Prefab. Site Fiber- Fxper <br /> INFORMATION New Existin Gallons Tanks Manufacturer's Name Concrete con- Steel glass Plastic App <br /> Tanks Tanks ^^ strutted <br /> Septic Tank q�ieldeng�arA DOO / eSirAte� ydI ❑ ❑ ❑ ❑ ❑ <br /> Lift Pump Tank/Siphon Chamber E1+0 ❑ ❑ ❑ ❑ <br /> VIII. RESPONSIBILITY STATEMENT <br /> I,the undersign tic a responsi llity for-instal tion of the onsite sewage system shown op ttached plans. <br /> Plumber's Wt)& EXCAVATIO I er s Signatu :(No Stamps) Vr/MPRSW No.: i �mber: <br /> VV a-7-487 <br /> �. <br /> Plumber's Address t tgq$Qt)Code). <br /> (715)835-7482 !_ <br /> IX. COUNTY/ DEPARTMENT USE ONLY <br /> Disapprove Sanitary Permit Fee 0 1 de,Grovndwater ate slue ssu na aramps)j// <br /> proved ❑Owner Given Initial '/67L)�'`hargetee) J/, <br /> Adverse Determination <br /> X. CONDITIONS OF APPROVAL/ REASONS FORDISAPPROVAL: <br /> ,1(H.05/94) DMR18UI'ION: Original to Cuorey,One copy To: Surety 8 RuilJings Diwvon,Owner,PlurnWr <br />