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^ 1* a. Safety and Buildings Division <br /> �. r•r'Ti SANITARY PERMIT APPLICATION Bureau a Building Water Systems <br /> 201 a Washington Ave. <br /> In accord with[LHR 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. k ��--\� <br /> • See reverseside for instructions for completing this application StateSanitart ermit Number <br /> The information you provide may be used by other government agency programs ❑Check d rev to previous application <br /> [Privacy Laws. 15iO4(i)(m)I. State Plan 1. -Number <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION SGI L C)oc)> 10 <br /> Property 0rName <br /> "'r—4 .V f S ,rqp ty Loc atl4 n5 a/ T 3:7 ,N, R 18V(or)W <br /> Property Owner's Mailing Address Lot Number lock Number <br /> o Q / &- of 13 <br /> City,St to / Zip Code I Phone Number Subdivision Name or CSM Number <br /> S /twl47 r 2U. oZ d )W -A"Dq <br /> II. TYPE F BUILDING: (check one) ❑ State Owned ❑ city Nearest Road <br /> ❑ village r l^ <br /> Public 1 or 2 FamilyDwelling- No. of bedrooms 3 Town oP V e <br /> .If Numbers) <br /> I. BUILDING USE: (If building type is public,check all that Parcel Tax <br /> 1 E] Apartment/Condo V' Lj 0 �� <br /> 2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Outdo r Recreational Facility <br /> 3 ❑ Campground 7 ❑ Merchandise: Sales/Repairs 11 ❑ Restau ant/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_ I$New 2_ ❑ Replacement 3. E] Replacementof 4. E] Reconnection of 5. ❑ Repair of an <br /> Ul System System Tank Only Existing Syst m Existing System <br /> _ <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 ❑Seepage Bed 21 ❑Mound 30❑Specify Type 41,R 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.) Proposed(sq.ft.) (Gals/day/sq. ft.) (Min./inch) EI vatio <br /> et n <br /> 7 Fe ,Od Feet <br /> TANK Capac <br /> VII. INFORMATION in allons Total #of Manufacturer's Name Prefab Fiber- Plastic Exper <br /> New Existin Gallons Tanks concrete stru ted Steel glass App. <br /> Tanks Tanks <br /> Septic Tank or Holding Tank oi06C1 W ® ❑ I ❑ 1 ❑ 1 ❑ <br /> Lift Pump Tank/Siphon Chamber ❑ 11 1 ❑ ❑ ❑ ❑ <br /> VIII. RESPONSIBILITY STATEMENT <br /> I,the undersigned,assume responsibility for installation of the onsite sewage system shown ontheattached plans. <br /> Plumber's Na e:(Pnnt) PcVe Si atur :(No St hikl PRSW No.: Business Phone Number: <br /> /6 U� 3-3 7/i--vz� 73J <br /> Plumber's Ad dr ss(Street,City,State,Zip Code): <br /> L U C •� LQ , Y S- <br /> IX. COUNTY/ DEPARTMENT USE ONLY <br /> I-]Disapproved Sanitary Permit Fee (In`mdea Grounawewr ate Issue Issuing AenZSig to e( Stamps) <br /> Approved F1Owner Given Initial l surefPe) c 1I <br /> co <br /> Adverse Determination {- -1 � <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> 580-6398(8.W94) DISTRIBUTION. Original w trinity,One copy To. Solety B Buildings Division,(Owner,Plum r <br />