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Safety an Buildings Division <br /> (Ei <br /> ; SANITARY 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 /> Madison,WI 53707-7969 <br /> • Attach complete plans(to the county copy only)for the system,on paper not less cl my <br /> than 8 1/2 x 11 inches in size. <br /> • See reverse side for instructions for completing this application State Sanitary Permit Number <br /> X195'70 <br /> The information you provide may be used by other government agency programs ElCheck I revision to previous application <br /> IPrivacy Law,s. 15-04(1)(m)]. State Plan I.D.Number <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION <br /> P ert Owner ame Property Location <br /> 0 S G� W1/4 Z( W1/4,S /S T 1/0 ,N, R/S <br /> Propert Owner's Mailing Address � � Lot Number Block Number <br /> TJ v t /a <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> 16111ecr lr A4rt 165"M? (612,)7 —60' JJ, 'its 1lo Vel fli <br /> II. TYPE OF BUILDING: (check one) ❑ State Owned ❑ City Nearest Road <br /> ❑ Village <br /> Public Z 1 or 2 Family Dwelling-No.of bedrooms Town OF k NPS 2)h <br /> III. BUILDING USE: (if buildingtypelspublic,checkallthatapply) Parcel TaxNumber(s) <br /> 1 ❑ Apartment/Condo 101�1 7 <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: (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 System ___ ______ TankOnly_____ ______ 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 MSeepage 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.) Propo ed(sq-ft.) (Gals/day/sq. ft.) (Min./inch) p Elevation <br /> '30 C 2 -3 , 70. S Feet Feet <br /> VII. TANK Capacity Site <br /> INFORMATION in gallons Galltons Tal a of <br /> Manufacturer's Name Cone este Con- steel glass Plastic Aper <br /> New Existin strutted <br /> Tanks Tanks r <br /> eptic Tan r Holding Tank 7J d f ® El n El El El <br /> I.ift Pump Tank/Siphon Chamber EJ ❑ E1 ❑ El 11 <br /> VIII. RESPONSIBILITY STATEMENT <br /> I,the undersigned,assume responsi ility for installation of the onsite sewage system shown on the attached plans. <br /> Plumber's Name:(Prin ) PI mber'sSignat re: n Stamps) MP/MPRSW No.. Business Phone Number: <br /> Yr <br /> Plumber's Address(St re t,ci ,State,Zip Co e) �,`�� <br /> V h � `F�Y tr l f, <br /> IX. COUNTY/ DEPARTMENT USE ONLY <br /> ❑Disapproved Sanitary Permit Fee (In`�udeseroundwater ate Issue Issuin Ag t Sign ture( amps) <br /> roved Surcharge tee) <br /> 7777CCCCYYYY ZK—pp ❑Owner Given al L'�a Qom' IV 7 29 <br /> Adverse Determination �./ 7 tJ <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SND-6398(R.05/94) DISTRIBUTION'. Original to Cnunty,One utPy To: Safety 8 Build'uv3>Divcion,Owner,PlumWr <br />