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Safety and Buildings Division <br /> �tiLlMin 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 ci3mplete plans(to the county copy only)for the system,on paper not less County. ����� <br /> than 8 1/2 x 11 inches in size. Lf IJ C' <br /> See reverse side for instructions for completing this application State Sanitary Permit Number <br /> 4�b <br /> The information you provide may be used b other government agency programs 303 }� r" <br /> y p y y g g y g ❑Gheck it revision to p evlous application <br /> [Privacy Law,s. 15.04(1)(m)I- State Pla�I.D.Number <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION (/G <br /> Property Owner Name Property Locatio / <br /> SEfZ F{O� 1/4 1/4,n S Z3 T t�{) ,N, R 16 E(or) <br /> Property Owner's Mailing Address Lot Number <br /> S ,4 . S. 4G <br /> C9,State Zip Code P one Number Subcl Ision Na a or CSM Number <br /> T �au> 1`4 o S ( 5?14 VOL- - f <br /> IL TYPE OF BUILDING: (check one) ❑ State Owned ❑ City Nearest Road <br /> Ej Public 1 or 2 Family Dwelling- No.of bedrooms 3 O Village OA ^ .1D 5-�DA' 50►J Lg IZn <br /> own OFlJ�1►�t_7'r{``�� <br /> III. BUILDING USE: (If building type is public,check all that apply) Parcel TaxNumber(s) <br /> 1 ❑ Apartment/Condo OZD -A'3-2� 0( goo <br /> 2 ❑ Assembly Hal[ 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- 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 A 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.Area3. Absorp.Area 4. Loading Rate 5. Perc. Rate 6. System Elev. 7. Final Grade <br /> Required .ft.) Pro os d(sq. ft.) (Gals/day/sq. ft.) (Min./inch) Elevation <br /> l/O [ 101.3 Feet 1 3.5$Feet <br /> VII. TANK Capacity site <br /> INFORMATION in gallons Galltal ons Tanks Manufacturer's Name cone ete con- steel glass Plastic nppr <br /> New Existin strutted <br /> Tanks Tanks <br /> Septic Tank or Holding Tank Iwo I Inm 41 41411101El 1:1 n n <br /> Lift Pump Tank/Siphon Chamber El EE31 1:1 ❑ ❑ <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 m is) MP/MPRSW No.: Business Phone Number: <br /> c X15 S S- X157 <br /> PI mber's Address( teeet,City,State Zip Code): <br /> X � <br /> 1-7 0 . 35 FS R 1 11 . X 93 <br /> IX. COUNTY/ DEPARTMENT USE ONLY <br /> E]Disapproved SanitaryPerm itFee 0ndc&5Groundwater atelssue Issum gentSignature(NoStamps) <br /> A roved Surcharge Fee) <br /> pp ❑Owner Given Initial <br /> Adverse Determination �V�' 06 J <br /> X. ONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SND-1;398(R.OS/94) DISTRIBUTION. Original to(nura y.One copy To: Satety 8 Ruildi ngn N,a-,.n,Owner,Pi.noWr <br />