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. Safety andBuildi�on <br /> SANITARY PERMIT APPLICATION Bur au of zhuillddt gign AWaeter Systems <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 8 112 x 11 inches in size. %U,,4A ( -7 7� <br /> • See reverse side for instructions for completing this application State Sanitary Permit Number <br /> The information you provide may be used by other government agency programs ❑C eck 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 INT ORMATI N iti <br /> MopOwn Nam Property Location <br /> I I $o,� NW1/4 1/4,533 T qO ,N, R -&(or)W <br /> Pi oplerty Owne 's Maili;g Address Lot NumbeyL Block Number <br /> l L.i r r 1 r. _.J <br /> City,State IZip Code Phone Number Subdivision Nam eyc CSM Number <br /> L4 I Wl SS ((e(z) 7 .-I03 Jays,-Uc Gid, <br /> II. TYPE OF BUILDING: (check one) ❑ State Owned 0 Cit N arest Road 7 <br /> ❑ Village !/}• / �( <br /> Public 1 or 2 FamilyDwellin - No.of bedrooms 1 Town OF O4L—tYrt.Qc �Tva+^e <br /> III. BUILDING USE: (If building type is public,check all that apply) Parcel Tax Number(s) <br /> 1 ❑ Apartment/Condo ;�C , g3oc _ I i � <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. [C'New 2. ❑ Replacement 3. E] Replacement of 4. E] Reconnection of 5- E] Repair of an <br /> I`-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 /> 11,9 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 /> 3� o <br /> Req ired (sq ft.) Proposed (sq. ft.) (Gals/day/sq. ft.) ( in./inc (] Elevation <br /> 2 Z el C] Feet 967 Feet <br /> TANK Capacct <br /> VII. INFORMATION in allons Total #Of Manufacturer's Name Prefab. Con- Steel site Fiber- i Exper. <br /> Gallons Tanks Concrete glass Plastic App <br /> New Existin strutted <br /> Tanks Tanks <br /> Septick or Holding Tank —7= t le ❑its ❑ ❑ ❑ ❑ <br /> Lift Pump Tank/Siphon Chamber ❑ ❑ ❑ ❑ ❑ -❑ <br /> Vill. RESPONSIBILITY STATEMENT <br /> I,the undersigned,assume responsibi h for installation of the onsite sewage system shown on the attached plans. <br /> Plumber's Name (P( t) Plu bersSignat r oStamps) MP/MPRSW No.: Business Phone Number: <br /> Ill <br /> Plumber's Address(Street, ity, tate,Zi e): <br /> ? Co D Gfl �- Wit 53 <br /> IX. COUNTY/ DEPARTMENT USE ONLY <br /> El Disapproved Sanitary Permit F e tln`Iudes G,oundwate, Date Issued- Issuin A n St tur tamps) <br /> roved � r0 e��„ba,geree) 6 <br /> pp ❑Owner Given Initial J �UY� (< <br /> Adverse Determination <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398 Bt 05N4) DISTRIBUTION. Original to county,One copy To: Safety B Nuililings Division,Owner,Plumber <br />