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Vr(litJ/�l.�l <br /> Safety and Buil ding Division <br /> ��� ..m.'• Bureau of Building Water Systems <br /> .■■,T.r. SANITARY PERMIT APPLICATION 201E-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 A <br /> • See reverse side for instructionsfor completing this application State Sanitary P rmnitNummbber <br /> The information you provide may be used by other government agency programs ❑Check rovrsit n to previous application <br /> (Privacy Law,s. 15.04(l)lm)], <br /> State Plan LD.Number <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMAT ON If <br /> PropertOENG wner Name Property Locationc; s L3 T Q ,N, R E (Or)® <br /> Propert Owner's Mailing Address Lot Num er Block Number <br /> Ow; <br /> SS AV. 313 Z <br /> City,State ZI Code Phone Number 4Subdivis�inNameorCSM Number <br /> aF s (_ Mtj - .�5 z9 (612 )536-036" PII. TY E FB ILDING: (check one) ❑ State Owned Nearest Road <br /> Public 1 or 2 FamilyDwelling- No. of bedrooms � Town F -:SAC_K50AJ INIEkLAMOtr112— <br /> i11. BUILDING USE: (If building type is public,check all thatapply) Parcel Ta Number(s) <br /> �. gSCn - /� -ata <br /> 1 ❑ Apartment/Condo <br /> 2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 1 10 ❑ Outdoor Recreational Facility <br /> 3 E] Campground 7 E] Merchandise: Sales/Repairs i <br /> i 11 ❑ Restaurant/Bar/Dining <br /> 4 ❑ Church/School 8 ❑ Mobile Home Park i 12 ❑ Service Station/Car Wash <br /> S ❑ Hotel/Motel 9 ❑ Office/Factory i 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. yNew 2. ❑ Replacement 3. ❑ Replacementof I <br /> 1 q. ❑ Reconnedionof 5. E] 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 /> 114 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 Rae S. Pert. Rate 6. System Elev. 7. Final Grade <br /> Required (sq. ft.) Proposed (sq.ft.) (Gals/day/sq.5 Z it.) (Min./inch) Elevation <br /> 1-50 0 , Z 3.9 Feet 110. q Feet <br /> Ca aut <br /> VII. TANK in gallons Total #of Prefab site Fiber- Exper <br /> INFORMATION Gallons Tanks Manufacturerl's Name concrete cp" steel glass Plasuc App <br /> New Existin strutted <br /> Tanks Tanks <br /> Septic Tank or Holding Tank SOO ❑ ❑ ❑ ❑ ❑ <br /> Lift Pump Tank/Siphon Chamber ' ❑ ❑ ❑ ❑ ❑ ❑ <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 Signaturre/( Stamps) M /MPRSWNo.: Business Phone Number: <br /> /c�{a12n DOWNS (t 3�Zb " is <br /> PIu ber'z Address(Street,City,State,Zip Co <br /> 7_7o gw 35, wt8m W'• (Sul <br /> IX. COUNTY/ DEPARTMENT USE ONLY <br /> E]Disapproved Sanitary Permit Fee Im.mdessroundwater ate is a uing Age Sign ture( amps) <br /> roved s�rrhar9e feel <br /> pp ❑Owner Given Initial /r e s�/ Qj ` / <br /> Adverse Determination ii C Gr lr� 'lr <br /> X. CONDITIONS OF APPROVAL/ REASONS DISAPPROVAL: <br /> SBD 6639a(It W94) 0191RIBUTION. Originalt,)Cnunly,Oneu,Py Tor Safety Ruadinge Olmimn,owner,Plumber <br />