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Oil cb­fy- <br /> Safety and Buildings Division <br /> �pi�: SANITARY PERMIT APPLIC TION Bureau ashingtonAvterSystem <br /> 201 E.Washington Ave. <br /> In accord with ILHR 83 05,Wis.Adm.Co a 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 8 112 x 11 inches in size. &&h5tr ` <br /> • See reverse side for instruct Iions for completing this application State Sanitary Pgrmit Number <br /> The information you provide may be u{ed by other government agency programs ❑Check it revision to previo application I rj <br /> [Privacy Laws. 15.04(t)(m)IJ <br /> � <br /> . State Plan LD.Number <br /> I. APPLICATION INFORM TION - PLEASE PRINT ALL INFORMATION 6- 20/ <br /> Prop rty O ner Naa Prop rty Location <br /> sW 1/4,S 6 T ,N, RE(or) <br /> Pro erty Owner's Mailm Address Lot Number Block Number <br /> CgSo <br /> City,State Zip Code Ph ne Nu ber Subdivisi n Name or CSM Number <br /> fjKAJ`M5U1ZQ VAI. 5 $ D > <br /> II. TYPE F BUILD G: (check one) E] ❑State Owned ❑ City Nearest Road <br /> ag D� <br /> Public 1 or 2 Famil Dwelling- No.of bedrooms 4 VillTown F oo Rw 40 <br /> III. BUILDING SE: (If building type is public,check all that apply) Parcell xNumber(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: (Ch ck only one box on line A. Check box on line B, if applicable) <br /> A) 1 ❑ New 2. N Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an <br /> System System ____ Tank Only---------------Existing System ExistingSystem <br /> B) ❑ A Sanitary Permitlwas previously issued. Permit Number Date Issued <br /> V. TYPE OF SYSTEM: (Ch ck only one) <br /> Non Pressurized Distribution) Pressurized Distribution Experimental Other <br /> 11 ❑Seepage Bed i 21 MMound 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. A sorp.Area 3. Absorp.Area 4. Loading Rate 5. Perc. Rate 6. System Elev. 7. Final Grade <br /> Req ired (sq.ft.) Proposed(sq.ft.) (Gals/day/sq. .) (Min./inch) 11- 3 Elevatiicm <br /> Wo 00 O , Z Feet .SD Feet <br /> CapaCit <br /> VII. INFORMATION in llons Total #of Prefab. site Fiber- Fxper <br /> g Gallons Tanks Manufactur is Name Concrete con- Steel glass Plastic App <br /> ew Existin strutted <br /> Tinks Tanks <br /> Septic Tank or Holding Tank I ❑ ❑ ❑ ❑ ❑ <br /> Lift Pump Tank/Siphon Chamber ❑ ❑ ❑ ❑ ❑ <br /> VIII. RESPONSIBILITY ST TEMENT <br /> I,the undersigned,assumeresponsibility for installation of the onsite Sewage system shown on the attached plans. <br /> Plumber's Name: (Print) Plumber's Signature:( o amps) P/MPRSW No.: Business Phone Number: <br /> !ct(AfZ3� r/SI 3�ZL S- wo- qIS7 <br /> PI mber's Address(Street,City,Stat ,Zip Code): <br /> I 35 StEK wI. SLfB <br /> IX. COUNTY/ DEPARTM T USE ONLY <br /> ❑DlSappr 4ved Sanitary Permit Fee (indudes6roundwmr , ate Issue Issuing ature o amps) <br /> pproved ❑ Ie „'1'suahnrge reel p <br /> Owner Giv n Initial <br /> Adverse D termination <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL <br /> SPI,b398(H U5n4) MKTRIBUTION Original ur Cnumy,Ona o,Py to: S.,tetyBPuilJing�Olmemn.Owner,Plumbar <br />