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,jFy 1 f e t _(� Safety and Buildings Division <br /> �AIl'`Il Bureau of Building Water Systems <br /> . .mom SANITARY PER IT APPLICATION 201 E.Washington Ave <br /> In accord with ILHR 83 05,Wis.Adm.Code P.O.Box 7969 <br /> V <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 1/2 x 11 inches in size. Bug ugc <br /> • See reverse side for instructions for completing this application State Sanital Permit Number,,? <br /> I kio <br /> The information you provide maybe used by other government agency programs [](tick it re un to previous application <br /> l Privacy Law,s. 15.04(1)(m)I_ State Plan I. Number <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION <br /> P roperlty Owner Name Property Locatii ns $ T �Q ,N, R E (Or W <br /> ej <br /> r— rj <br /> Property Owner's Mailing ddress Lot Number Block Number <br /> -fhFL Pel. --o ;,L. L <br /> Cit),State Zip Cod P ne N be Subdivision Name or C M N her <br /> Csmenc� nc <br /> 11. TYPEF BUILDI G: (check one) ❑ State Owned Ll State Nearest Road <br /> ❑ Village C,,_71- <br /> El Public 1 or 2 FamilyDwelling- No. of bedrooms Z Town of N 0- <br /> 111, BUILDING USE: (If building type is public,check all that apply) Parcel Tax Number(s) <br /> 1 ❑ Apartment/Condo I t;� L4�Q23 <br /> 2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility <br /> 3 ❑ Campground 7 ❑ Merchandise: Sales/Repairs 11 ❑ Resta rant/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_ Tszf'New 2. D Replacement 3. E] Replacement of 4_ E] Reconnecti n 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 /> 1ASeepageBed 21 ❑Mound 30❑Specify Type 41 ❑Holding Tank <br /> 1 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 PerDay 2. Absorp.Area 13. Absorp.Area 4. Loading Rate 5. Perc. Rate E. System Elev. 7. Final Grade <br /> Re fired (sq.ft.) Prop sed(sq. ft.) (Gals/ y/sq.ft.) (Min./inch) Elevation <br /> 3Q , /'7 , Feet -6 Feet <br /> TANK Ca acit <br /> VII INFORMATION in gall0 5 Total #Of Prefab. a Fiber- plastic Exper <br /> Gallons Tanks Manufacturer's Name Concrete C n- Steel glass App <br /> New Existin str icted <br /> Tanks Tanks /� <br /> Septic Tank or Holding Tank Q '� 4q El ElEl ❑ <br /> lift Pump Tank/Siphon Chamber ❑ ❑ ❑ 1 ❑ ❑ <br /> VIII. RESPONSIBILITY STATEMENT <br /> I,the undersigned,assume responsibility for installation of the onsite sewage system shown n the attached plans. <br /> Plumber's Name:(Print) Plumber'i Signature: N 5 ps) MP/MPRSW No : Business Phone No r: <br /> D N Z� S 15 <br /> PI mber's Ad dress IStreetStt Z <br /> ,City, a , ip Code): <br /> 27710 o W 35 W I 893 <br /> IX. COUNTY/ DEPARTMENT USE ONLY <br /> ❑Disapproved Sanitary Permit Fee (includes Groundwater rate ssue Issuiii Agent Signature(No Stamps) <br /> Scr,Approved ❑ nar9eTeelOwner Given Initial Imo. ; 3R. ✓ r ' � <br /> Adverse Determination Jl., <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(It.nsico DKTRIBUTION. On,inalmCounly.OneaoPYT.:Sa Ge,,&Bell,h no,Di moon,Owner,Plum r <br />