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SANITARY PERMIT APPLICATION Safety of Building <br /> Division <br /> Bureau a Building Water System201 E. . <br /> In accord with[LHR 83 05,Wis.Adm.Code P O Box77969gton Ave. <br /> Madison,Wl 53707-7969 <br /> • Attach complete plans(to the county copy only)for the system,on paper not less County <br /> than 8 vz x 11 inches in size. Bu r <br /> • See reverse side for instructions for completing this application StateSamtar it Number S(i? g.3 <br /> The information you provide may be used by other government agency programs ❑Check a rev cion previous application <br /> [Privacy Law,s. 15.04(1)(m)I. State Plan I.D.Number <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION <br /> Prope Own r Name Property Location O6 <br /> S eA 9471l4 rVt 1/4,S TL' ,N, R& E (oro <br /> Pro erty Owner' ai ling Addres} Lot Number lock Number <br /> �oZPo:2 (sc-// 7r,41 / -- — <br /> City,StateZip Code Phone Number Subdivision Name or CSM Number <br /> ,0 A)6 r C.vr 5 ys� 0 1( )8kl-&,2$/ <br /> II. TYPE AOF BUILDING: (check one) ❑ State Owned E] Ity Nearest Road <br /> El Village <br /> El Public M1 ort Family Dwelling-No. of bedrooms _,X_ Town or C>AK S Ga / Tri'}/ <br /> 111. BUILDING USE: (If building type is public,check all that apply) Parcel Tax Number(s) <br /> 1 ❑ Apartment/Condo — �� - c2 nn <br /> 2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Outdoor 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. ❑ New 2. Replacement 3. ❑ Replacement of 4. ❑ Reconnectio of 5. ❑ Repair of an <br /> System System Tank Only Existing Syst m Existing System <br /> ------ ----------------- ----------------------- <br /> B) ASanitary Permit was previously issued. Permit Number Date Issued ,j,;�J—'7) <br /> V. TYPE OF SYSTEM: (Check only one) <br /> Non Pressurized Distribution Pressurized Distribution Experimental Other <br /> 11 ®,Seepage Bed 21 ❑Mound 30 E]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 /> Require (sq. ft.) Proposed (sq. ft.) (Gals/day/sq.ft.) (Min./inch) Elevation <br /> o C) y i G9 9_s Feet Y7 4 Feet <br /> TANK a aclt <br /> VII INFORMATION n gallons Total #of Manufacturer's Name Prefab coy_ Fiber- Exper <br /> Gallons Tanks Concrete Steel glass Plastic App <br /> New_____F Gallons strut ted <br /> Tanksl Tanks <br /> Septic Tank or Holding Tank 0 l 7 /Y1 L ❑ 2 ❑ ❑ ❑ <br /> L ift Pump Tank/Sip hon Chamber ❑ ❑ ❑ ❑ ❑ <br /> VIII. RESPONSIBILITY STATEMENT <br /> I,the undersigned,assume responsibility for installation of the onsite sewage system shown on the attached plans. <br /> Plumber's Name:(Print) '3;,40 <br /> / Plumber's Signature:(No mps) MP/MPRSW No.: usmess Phone Number: / <br /> U/ S, d/tet �� �.�-�c._ �/ 03 <br /> Plumber's Address(Street,City,State,Zip Code). r <br /> /od <7 n k• _j/y -.5"1/ e.�ti ov%r J Sig 7 2 <br /> IX. COUNTY/ DEPARTMENT USE ONLY <br /> E]Disapproved Sanitary Permit Fee Imdude,erovndwmer Date Issued Issum ent Sig ure(No Stamps) <br /> Su"ha,V t eo <br /> XApproved ❑Owner dverse en etermii Iso"M <br /> 7_1, <br /> Adverse Determination ' <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> s8U-6398 of 05194) DISTRIBUTION. Original to Cnumy.One mpy To. Sulety 8 Buildings Divcion,Owner.Plume <br />