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Safety`d Buildings <br /> ivision <br /> Bureau of Building water Systems <br /> SANITARY PERMIT APPLICATION 201 E.p.0. gton Ave <br /> Box 7wl969 <br /> Madisonan53707-7969 <br /> (9In afford with,LHR B3.05,Wis.Adm.Code <br /> on for the system,on paper not less county lL �9 <br /> complete plans(to the county copy Y) 4/i^/v e <br /> • Attach comp State Sanitary Permit Number <br /> than 81/z x 11 inches in size. <br /> letin this application {^q <br /> 6 revio s application <br /> • See reverse side for instructions for comp 9 chat ;iision t p <br /> provide may be used by other government agency programs — <br /> State Plan .D.flu=6ef � S � <br /> The information, p 6 <br /> ,Privacy Law,S. 15.04(1)(m)1- -9 <br /> Property Location N R/Sy E(or \ <br /> I, APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION 1/4,S <br /> �y T .3g J" <br /> pro rtyOwn rName r p Block Number S <br /> Owner's Mailing Address In d- t �. <br /> Property ame or CSM Number <br /> a Zip code Phone Number U/vho 07 81 <br /> it ,5 t > m � ( ) El it Nearest Road <br /> State Owned L3 Rage G�co�l ,Je <br /> II. TYPE F BUIL ING: (check one) ❑ Town of 12 <br /> c il Dwelling.-No.of bedrooms parcel Tax Number(s) <br /> Publi1 or 2 Fam <br /> III. ckllthatapplyl <br /> BUILD (it <br /> � Say Z O t , 73E � <br /> ❑ Apartment/Condo 10 C] outdoor Recreational Facility <br /> 1 <br /> 6 ❑ Medical Facility/Nursing Home 11 ❑ Restaurant/Bar/Dining <br /> 2 ❑ Assembly Hall 7 ❑ Merchandise:Sales/Repairs 12 ❑ Service Station/Car Wash <br /> 3 ❑ Campground 8 ❑ Mobile Home Park 13 ❑ Other: specify <br /> 4 ❑ Church/School 9 ❑ office/Factory <br /> 5 Hotel/Motelbox applicable) <br /> Reconnection of 5. ❑ Repair of an <br /> IV. TYPE OF PERMIT: (Check only one box on line A. checement of ine B,i 4 Existing System <br /> Existing S stem __ <br /> Replacement 3. ❑ _g-Y------------ <br /> New 2. Tank Only ------------ -- <br /> A) 1. ❑ stem -------- Date Issued <br /> System ---------y----------------- <br /> g) ❑ A Sanitary Permit was previously issued. Permit Number <br /> Other <br /> V. TYPE OF SYSTEM: (Check only one)Pressurized Distribution Experimental 41 C]Holding Tank Non-Pressurized DistributiM30 C]Specify Type <br /> 21 ound 42❑Pit Privy <br /> 11 ❑Seepage Bed 22❑In-Ground Pressure 43❑Vault Privy <br /> 12❑Seepage Trench <br /> 13❑Seepage Pit <br /> 14❑System-In-Fill <br /> VI. ABSORPTION SYSTEM INFORMATION: Area 4. Loading Rate 5.Perc. Rate 6. System Elev. Elevation- Final rade <br /> 2. Absorp.Area 3. Absorp. ft Gals/day/sq.ft) (Min/Inch) G�•� Feet Q� Feet <br /> 1.Gallons Per Day Required(sq.ft.) Proposed(sq. ) ( / a -- <br /> �0 �5–o ;25—.2 Expe <br /> Prefab. Site Fiber- plastic App <br /> Capacity Total #Of Concrete Con- Steel glass <br /> VII. TANK in gallons Manufacturer's Name strutted <br /> INFORMATION New Existin <br /> Gallons Tanks ❑ ❑ <br /> Tan�kys� Tanks 5O ❑ ❑ ❑ <br /> Septic Tank or Holding Tank 00 GU <br /> t7(J <br /> Lift Pump Tank/Siphon Chamber laps. <br /> VIII. RESPONSIBILITY STATEMENT e system shown on the attached p <br /> MP/MFRSl.1'/ Busin3Pho�Nul�er; �� <br /> I,the undersigned,assume responsibilfl pl ity <br /> installation of the onsite sewag cr- <br /> Plumber's Name:(Prin <br /> -nber's Address(Street,City,State,ZS lA /v f <br /> ,0)1S111 <br /> `— s <br /> (Includes Groundwater ate ?sue Issuing A e Signa re( p) <br /> )UN FY/DEPARTMENT USE ON Sa ita Fermi F1 Fee Surcharge Fee) <br /> ❑Disapproved <br /> ped ❑0 r Given Initial <br /> Adverse Determinatlon <br /> 'ONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> DISTRIBUTION: Original to coa.,,.One capy To: Safety 8 ituildings Division,Owner,P.I,U.Mb I er <br /> 11 r <br />