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J)/I- CA TL�o <br /> Safety and Buildings Division <br /> ESANITARY 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 County p <br /> than 8 1/2 x 11 inches in size. (,( �l) <br /> • See reverse side for instructions for completing this applicationtesary Qrrmic Ny n er <br /> The information you provide may be used by other government agency programs ❑Check it revision to prev us application ^' <br /> [Privacy Law,s. 15.04(1)(m)I. State Plan I.D.Numb r ^ <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION Al <br /> Prop rty O er Name Property Location <br /> L� 1/4 1/4,S 7 T 1 b ,N, R J5 E(o W <br /> PropertOwner's Mailing Address Lot Number B1pek-WyrKbpr <br /> ZgS _5 ^45C,6R RD_ I L- <br /> City,State Zip Code one Number Subdl ision Name or CSM Number <br /> W) $30 ( 8 U? <br /> II. TYPE BUILDING: (check one) ❑ State Owned ❑ City Nearest Road <br /> ❑ Village <br /> Public 1 or 2 Famil Dwellin - No. of bedrooms Town OrSPIICKSXj 5 <br /> III. BUILDING USE: (If building type is public,check all that apply) Parcel Tax Number(s) <br /> 1 ❑ Apartment/Condo JZ 47o-7 oR (00 <br /> 2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility <br /> 3 Q Campground 7 ❑ Merchandise: Sales/Repairs 11 ❑ Restaurant/Bar/Dining <br /> 4 ❑ Church/School 8 Q Mobile Home Park 12 ❑ Service Station/Car Wash <br /> 5 ❑ Hotel/Motel 9 Q Office/Factory 13 Q Other: specify <br /> IV. TYPE OF PERMIT: (Check only one box on line A. Check box on line B, if applicable) <br /> A) 1_ Q New 2. g Replacement 3. ❑ Replacement of 4. Q Reconnection of 5. Q 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 /> 11 m Seepage Bed 21 []Mound 30❑Specify Type 41 ❑ Holding Tank <br /> 12 a 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 S. Perc. Rate 6. System Elev. 7. Final Grade <br /> Required (sq. ft.) Proposed(sq. ft.) (Gals/day/sq.ft.) (Min./inch) ��77 Elevation <br /> 3O : • 7 W— ,G– Feet g . 7 Feet <br /> Capacit <br /> VII. i FORMATION in allo s Total #of Manufacturer's Name prefab. Con Steel Fiber- plastic Exper <br /> New Existing Gallons Tanks Concrete strutted glass App <br /> Tans Tanks <br /> Septic Tank or Holding Tank 250i1•-1 ® ❑ E] ❑ El 1:1t ift Pump Tank/Siphon Chamber 1 TO 1752 I 1 VJ CF ® ❑ ❑ ❑ ❑ ❑ <br /> VIII. RESPONSIBILITY STATEM NT <br /> I, the undersigned,assume responsibility for installation of the onsite sewage system shown on the attached plans. <br /> Plumber's Name:(Print) Plumb�er/'s Signature:(No mps) MP/MPRSW No: Business Phone Number: <br /> I c�I Rl n o P fJs I�L{ZM./+ 42b /S- 866- 15l <br /> lumber's Address(Street,City,State,Zip Co� <br /> (00 W <br /> IX. COUNTY/ DEPARTMENT USE ONLY <br /> E]Disapprove Sanitar PermltFee (Includes Groundwater F// <br /> t Issue IssumgA n (gnat e <br /> Approved ❑ v/�Surcharge fee) <br /> Owner Given Initial yj3'" bb <br /> Adverse Determination ate` D <br /> X. CONDITIONS OF APPROVAL/ REASONS FOR DISAPPROVAL: <br /> SBD-6398(R.05/94) DISrRIBUTIoN'. Original to County,One copy To: Safety 8 Buildings Divwon,Owner,Plumber <br />