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Safety and Buildings Division <br /> SANITARY PERMIT APPLICATION Bureau of Building Water System <br /> .V•IL�•I"• 201 E-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 8 112 x 11 inches in size. " v <br /> • See reverse side for instructions for completing this application State Sanitary Permit Numb r <br /> asejf c5 <br /> The information you provide may be used by other government agency programs ❑Check it revision to 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 /> Property Owner Name Property Location <br /> �3 i,� - _ o'f 1-1/4,Sot y T 4j c) ,N, R1.G E (or):� <br /> Prope y Owner's Mailing Address Lot Num r Block Nube� <br /> P� 73ov ,z -t 3+v m <br /> City,Stat/e Zip Code Phone Number Subdivisl Na eor CSM Number 0/ P .2 /S <br /> /'egH'iG c'.✓� v£�3 7 &1739 <br /> II. TYPE OFBUILDING: (check one) El State OwnedElity Nearest Road <br /> Village �k. <br /> ❑ Public 3,J or 2 Family Dwelling- No.of bedrooms Town OF 0 A kli,;,l ok,)s 'l <br /> LChurch/School <br /> USE: (If building type is public,check all that apply) Parcel Tax Number(s) <br /> ent/Condo �0 — y3A - � � — o co o <br /> ly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility <br /> ound 7 ❑ Merchandise: Sales/Repairs 11 ❑ Restaurant/Bar/Dining <br /> /School 8 ❑ Mobile Home Park 12 ❑ Service Station/Car Wash <br /> 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- pg Replacement 1 ❑ Replacement of 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 21 E]Mound 30 E]Specify Type 41 E]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) p Elevation <br /> 000 600 9y$ I _ / 7�2- Feet 715,5' h Feet <br /> VII. TANK Capacity Site <br /> in gallons Total # k Manufacturers Name Prefab. Con- Steel Fiber- plastic Aper. <br /> INFORMATION Gallons Tanks Concrete glass App <br /> New Existin strutted <br /> Tanks Tanks <br /> Septic Tank or Holding Tank J O 2_ <�> 4 ® E <br /> El El El 0 <br /> Lift Pump Tank/Siphon Chamber 633 633 S'�iR�✓ <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/MPRSWNo.: Business Phone Number <br /> Plumber's Address(Street,City,State,Zip Code): <br /> ,6 0 X Si y S// � ,_) Lam- 5-y872 <br /> IX. COUNTY/ DEPARTMENT USE ONLY <br /> ❑Disapproved Sanitary Permit Pee tinduaescmunawerer ate s ue Issuing Age Sig atu Stamps) <br /> roved ge Vee) <br /> fiTt App ❑Owner Given Initial /�� C' <br /> 7� Adverse Determination Is" <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SHO-6396(8 05/94) )MRIRUTION'. Origlnzi ro Cmua y,oneu+IHTu:SaletyBPuiLlln,j�0'me.iun,Owner,Plumber <br />