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�n Cid <br /> p" <br /> Safety and.Bwldm s Division <br /> SANITARY PERMIT APPLICATION Bureau of Building Water System <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 �q / <br /> than 8112 x 11 inches in size. YyI CJ <br /> • See reverse side for instructions for completing this application State Sanitary Perm(iittt Number <br /> 93 <br /> The information you provide may be used by other government agency programs E] evi <br /> Check i rsion't//o prevz-plication <br /> (Privacy Law,s. 15.04(t)(m)]. State Plan I.D.Number <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION q� '" 10 3S <br /> Property Owner Name l e rPropert Location <br /> t( QQ� ytt In 1 Jt. IA �ti4,S (Z T � rN. R <br /> Property Owner's Mailing Address Lot Number / _ Block Number <br /> 12.36 n�eY cl.��. ,4�tov� <br /> CIt ,Stat Zip Code Phone Number Subdivision Name or CSM Number <br /> $ I((a?,)7 3S- 79Z- �Jr< (5 F)ektCL <br /> II. TYPE OF BUILDING: (check one) ❑ State Owned ❑ ity Nearest Road <br /> ❑ vii age <br /> E] Public 1 or 2 FamilyDwelling- No. of bedrooms Town of Yt <br /> ill. BUILDING USE: (If building type is public,check all that apply) Parcel Tax Number(s) <br /> 1 ❑ Apartment/Condo d 3 qo,.IT- © 00 <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 ___ ___ExistingSystem <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 41XHolding 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) Elevation <br /> Feet Feet <br /> VII. TANK Capacity Site <br /> INFORMATION a gallons Gallons Tanks Manufacturer's Name Concrete con- steel glass Plastic App- <br /> New Existin strutted <br /> Tanks Tanks <br /> Septic Tank rHolding TanE1 EjElEl 1:1 <br /> Lift Pump Tank/Siphon Chamber I F El 0 El Ej Ej Ej <br /> VIII. RESPONSIBILITY STATEMENT <br /> I,the undersigned,assume responsi •lity for installation of the onsite sewage system shown on the attached plans- <br /> PI ber'�Name:(vrey- <br /> PI mber's.5 gnatu o Stamps) MP/MPRSW No.: Business Phone Number: <br /> SS was �9 8�6 <br /> Pumber'sAddress tree ,City,Stat,Zip Code): <br /> ( f <br /> IX. COUNTY/ DEPARTMENT USE ONLY <br /> ❑Disapproved Sanitary Permit Fee (includes Groundwater ate ssue Issuing A en igna ure(N a ps) <br /> surchargefee) <br /> ❑ av vrQ <br /> ved Owner Given Initial <br /> eterminaAdverse 50�� ' <br /> X. CONDITIONS OF APPROVAL/ REASONS FOR DISAPPROVAL: <br /> 581-6398(it.05/94) DISTRIBUTION: Original to(nerd y.One mPy To: SafetyBRuildinge Division,Owneq Plumbar <br />