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Safety and Buildings n <br /> Bureau of Building mi <br /> SANITARY PERMIT APPLICATION e Water Syste <br /> 201 E.Washington Ave. <br /> In accord with ILHR 83.05,Wis.Adm.Cod P.O.Box 7969 <br /> Madison,WI 53707-7969 <br /> • Attach complete plans(to the county copy only)for the system,on paper i of less County �� � <br /> than 8112 x 11 inches in size. <br /> • See reverse side for instructions for completing this application state Sanitary Permit N her <br /> The information you provide may be used by other government agency programs Check if revision to previous application <br /> [Privacy Law,s. 15 04(1)(m)I. State Planler <br /> .D Numby�y <br /> I. APPLICATION INF RMATION - P A RINT ALL INFORMATI N � �a a � 3 V^t <br /> Property Owner Name Prope ty Location <br /> 0 d 1/4 1/4,5 7 T KO ,N, R Iq E(or <br /> Property wner's Mailing Address Lot Numb(r pi� <br /> Da rilZ <br /> Cit ,State Zpfode Phone Number SubdivisionNam r V ber� <br /> A 2310 ( )254.3910 / <br /> II. TYPE UF UILDING: (check one) ❑ State Ownedit Nearest Road <br /> Village <br /> 14 Public 1 or 2 Famil Dwellin - No.of bedrooms 60 FrTown CF .51207L <br /> III. BUILDING USE: (If building type is public,check all that apply) Parcel Tax Number(s) 93ao -03-1 at�� <br /> 1 ❑ Apartment/Condo a L, <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 /> S ❑ 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. ❑ Replacement 3- ❑ Replacement of 4- ❑ Reconnection of 5. ❑ Repair of an <br /> System SXstem 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 N Seepage Bed 21 ❑Mound 3 0❑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. Absgrp.Area 3. Absorp.Area 4. Loading Rat 5. Parc. Rate 6. System Elev. 7. Final Grade <br /> Required (sq. ft.) Proposed(sq.ft.) (Gals/day/sq. ft) (Min./inch) Elevation <br /> ZOO I' � b .7 i�� l Feet S3.Z Feet <br /> TANK Capacity VII. INFORMATION in gallons Total #of Manufacturer' Name Prefab Site <br /> Fiber- Plastic Exper <br /> New Exist1n Gallons Tanks Concrete strutted Steel glass App <br /> Tans Tanks <br /> Septic Tank or Holding Tank 0O ' KA ❑ ❑ ❑ ❑ ❑ <br /> I ift 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 Signature: oS mps) MP/ PRSW No.: Business Phone Number. <br /> ItFfRKD PK7NS `� IS- 86b- (11S 7 <br /> Plumber's Address(Street,City,State,Zip Code). <br /> 7-7-760 9W4 35 EB I , -51893 <br /> IX. COUNTY/ DEPARTMENT USE ONLY <br /> El Disapproved Sanitary Per it Fee (includes Groundwater ate Issued ssu ng Agen ig atu Stamps) <br /> Approved ❑Owner Given Initial / / �s r`nargefeel j n r <br /> ' \ Adverse Determination (` U o <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SHE-639l 05/94) DISTRIBUTION: Original to County.One copy To: Safety 8 B lardirl,Division.Owner,plumber <br />