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Safety and Buildings Division <br /> rSANITARY 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 /> DiLm <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. E a2 <br /> • See reverse side for instructions for completing this application State Sanitary Permit Numb <br /> 3�/ 700 <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)). State Plan I.D.Number <br /> i. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION 9 7 /.0 ,7 <br /> Property Owner Name Property Location <br /> 1/4 1/4,S 3 T 37,N, R l E(o W <br /> Property Owner's Mailing Addre s Lot Number Block Number <br /> X567 sa 4 .�f 2-3 :f S <br /> City, to Zip Code Phone Number Subdivision Name or CSM Number <br /> P4 AJ; I a ( 71T) 057 3.23/ /�orl�li t✓ir L. s 6,ri.r i&-*K- <br /> II. TYPE OF BUILDING: (check one) ❑ State Owned Ity N=1A <br /> ❑ Village <br /> Public 1 or 2 FamilyDwelling-No.of bedrooms _ Town of 5K -2 9af ZX <br /> III. BUILDING USE: (If building type is public,check all that apply) Parcel TaxNumber(s) <br /> 1 ❑ Apartment/Condo �V 9Oi6-a- <br /> 2 <br /> x-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. p New 2. 1K Replacement 3. E] Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an <br /> System System Tank Only -- ------ Existing System - ---Existing System <br /> ------------------------------------- <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 R 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. Final Grade <br /> Required (sq� ) Proposed(sq.ft.) (GalsJday/sq. ft.) (Min./inch) Elevation <br /> Feet Feet <br /> VII. TANK Capa ity site <br /> INFORMATION in gallons Galltal ons Ta of <br /> Manufacturer's Name ConcPrefrete Con- Steel glass Plastic Appr <br /> New Existingstrutted <br /> Tanks Tanks <br /> 59p4i*-marykor Holding Tank 000 ® ❑ Ej Q Q El <br /> Lift Pump Tank/Siphon Chamber <br /> VIII. RESPONSIBILITY STATEMENT <br /> I,the undersign s{gme responsibility for install ion of the onsite sewage system shown on the attached plans. <br /> Plumber'sAME�'1ffl L�I�t �XCAVATiO lu her' ignatur :(No Stamps) /MPRSW No.: Business Phone Number: <br /> gii.r G Coup Line Rd. <br /> Plumber's Addres Gi 2 pCode): <br /> (915)B 748 <br /> IX. COUNTY/ DEPARTMENT USE ONLY <br /> ❑Disapproved Sanitary Permit F (1ndade'crovndwater ate Issue Issuing Agent S nature(No a s) <br /> roved L✓/ ��reel � <br /> Opp ❑OwnerGivenInitial ( �' 7 <br /> `�V.I Adverse Determination <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SHO-6398(R OY94) DISTRIBUTION: Original to(nerdy,One copy To: Satety&Huildinyi Divr ion,Owner,Plumber <br />