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Safety and Buildings Division <br /> �■■ ■ Bureau of Building Water Systems <br /> SANITARY PERMIT APPLICATION 201 E Washington Ave <br /> In accord with ILHR 83 05,Wiz.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 8 112 x 11 inches in size- 'eGt r✓/e- <br /> ■ See reverse side for instructions for completing this application State Sanitary Permit Number <br /> ,;2,51� Zc;Z <br /> The information you provide may be used by other government agency programs ❑Check it revision to previous applicaliun <br /> Privacy Law,s. 15.04(1)(m)I State Plan I.D.Number <br /> 0 '116— <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION 17111 <br /> Property Owner Na e Property Location <br /> 5;>e� e_ y c.I nJr�e/`jar✓ 1/4 1/4,S oZ �' T a S' ,N, R /k E(Or <br /> Property Owner's Mailing Address / Lot Number. Block Number_ <br /> 9-:;zC/v;./ d <br /> City,{tate Zip Code Phone Number Subdivision Name or CSM Number - o <br /> —,T/d'e.-u I 3vk'7-2 <br /> 11. TYPE F BUILDING: (check one) ❑ State Owned ❑El Cit Nearest Road <br /> Vilage ✓�L' <br /> Public 1 or 2 FamilyDwelling- No. of bedrooms LJ3d: �7 Town OF /���� wad k <br /> III. BUILDING USE: (If building type is public,check all that apply) Parcel Tax Number(s) <br /> 1 ❑ Apartment/Condo '* <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 /> S ❑ 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. KReplacement 3_ ❑ Replacementof 4. ❑ Reconnection of 5- ❑ 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 Seepage Bed 210 Mound 30❑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 /> Required (sq. ft.) Proposed(sq.ft.) (Gals/day/sq.ft.) (Min./inch) Elevation <br /> C) 0 y,� 'Sloe-) .S 97. Feet 0-5e.. " Feet <br /> Ca <br /> VII. TANK galloalt ns Total #Of Prefab. Site Fiber- plastic Aper <br /> INFORMATION <br /> Gallons Tanks Manufacturer's Name Concrete con- Steel glass App. <br /> New Exiztin strutted <br /> Tanks Tanks <br /> Septic Tank or Holding Tank 7s°" 75"D ❑ ❑ <br /> Lift Pump Tank/Siphon 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) Plumber's Signature:(No Stamps) MP/MPRSW No.: Business Phone Number: <br /> Plumb 's Aciclo(Street,City,State,Zip Code): <br /> 70 wok Sr S ;, e .T, 4-_�77 <br /> IX. COUNTY/ DEPARTMENT USE ONLY <br /> C]Disapproved Sanitary Permit Fee (includes Groundwater ate Issue Issum A nt5i ore N tamps) <br /> Approved ❑Owner Given Initial /� OCArt,hargeFen) 3 / <br /> Adverse Determination 50 �Ui% !7 <br /> X. CONDITIONS OF APPROVAL/ REASONS FOR DISAPPROVAL: <br /> Mir096(H.05194) DMIRIBUTION'. Original to Cnuniy.One Cn,To: Sutety a ft J&ng)Di mucin,Owner,PlumGar <br />