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SANITARY PERMIT APPLICATION Safety andBui"Ing2ivision <br /> Bureau of Building Water System- <br /> In accord with ILHR 83 05,Wis.Adm.Code 201 E.Washington Ave. <br /> 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 8lrz x 11 inches in size. u� .1.7 <br /> • See reverse side for instructions for completing this application stor <br /> ate Sanitary Permit Nu fiber / <br /> The information you provide may be used by other government agency programs Check 8II7 77 <br /> [Privacy Law,s. 15.04(1)(m)]. ❑ it revision 10 previous application <br /> State Plan I.D. ber <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION <br /> Property Owner Name Property Location <br /> 1/4 1/4,S �?3 T 40 ,N, R E(or) <br /> Property Owner's Mailing Addr ss Lot Numberznx 47-L4 <br /> �yy@r <br /> �. 5 <br /> Gty, tate Zip Code Phone Number Subdivision Name or CSM Number <br /> c oc oza 1(215 )7_11-2141. <br /> if. TYPE OF tSI DING: (Check one) ❑ State Owned it� Nearest Road <br /> Public 1 or 2 Family Dwelling- No. of bedrooms Z ❑ vii age <br /> IQ Town OF <br /> III. BUILDING USE: (If building type is public,check all that apply) Parcel TaxNNumber(s) fV� <br /> 1 ❑ /�Apartment/Condo v 5 3w <br /> 2 E] Assembly Hal[ 6 E] Medical Facility/Nursing Home P 10 ❑ Outdoor Recreational Facility <br /> 3 ❑ Campground 7 ❑ Merchandise: Sales/Repairs 11 ❑ Restaurant/Bar/Dining <br /> 4 ❑ Church/School 8 ❑ Mobi[eHomePark 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_ -W Replacement 3- ❑ Replacement of 4. Reconnection of <br /> S stem Tank ❑ 5. Repair of an <br /> ______Y ________S---- y _ 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 []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 /> 3O0 375 3?S g L)S,p Feet 107.5 Feet <br /> VII. TANK n gallons Total #of site <br /> INFORMATION Gallons Tanks Manufacturer's Name Prefab con- glass Plastic Aper <br /> iNew]Existin, Concrete SteelTanks struttedSeptic Tank or Holding Tank ) A)WEl Ej ❑ ❑ ❑ <br /> Lift Pump Tank/Siphon Chamber 66 n El El ❑ ❑ O <br /> VIII. RESPONSIBILITY STATEMENT <br /> 1,the undersigned,assume responsibility for installation of the onsite sewage system shown on the attached plans. <br /> Plumber's Name;(Print) Plumbei Signature: No amps) MP/MPRSW No.: Business Phone Number: <br /> lCH o kiA/s 47-6IS- 6 /57 <br /> Plumber's Address(Street,City, tate,Zip Code) <br /> Z'7 6o w 3S v,166sreg .5 g8 3 <br /> IX. COUNTY/ DEPART ENT U5E ONLY <br /> ❑Disapproved St." Permit Fee (Mliude,Groundwater at sue Issuin nt5i ature ps) <br /> ❑Approved ❑OwnerGiven Initial �Q ` surchargaree) <br /> Adverse Determination l/.��7v\ (l <br /> X. CONDITIONS EA ONS FORO <br /> SBD-6398(8.05N4) DISTRIBUTION: Original to County.One<opy To: Safety 8 Building,oivuiun,owner,Plumber <br />