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Y , <br /> Safety and Buildings Division <br /> SANITARY PERMIT APPLICATION Bureau of Building Water System <br /> 201 E.Washington Ave. <br /> In accord with ILHR 83 05,Wis.Al.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 81/2 x 11 inches in size. <br /> • See reverse side for instructions for completing this application St t(-e Sanita PermitNumber <br /> The information you provide maybe used by other government agency programs Check t revision to previouapplication <br /> [Privacy Laws. 15iO4(1)(m)I State-Plan L .N mber <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION <br /> Propert caner Na Property Location <br /> SK 1/4 1/4,S Z% T ,N, RE(or <br /> Property Q ner's Maifng Arldress Lot Number) S lock Number <br /> City,State -•"� Zip ode Phone Num a Subdivision Na or CSM Numb r <br /> N100 ( ) pE �z. ' <br /> II. TYPE UILDING: (check one) ❑ State Owned ❑ C t Nearest Road <br /> Public 1 or 2 FamilyDwelling- No.of bedrooms vownneOF q�N <br /> LChurch/ <br /> USE: (If buildingtype lspublic,check allthatapply) Parcel Tax Numbers) <br /> Apartment Condo O �qcc -O _&0 <br /> ly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility <br /> ound 7 ❑ Merchandise: Sales/Repairs 11 ❑ Resta rant/Bar/Dining <br /> /School 8 ❑ Mobile Home Park 12 ❑ Servic Station/Car Wash <br /> Motel 9 ❑ Office/Factory 13 ❑ Other specify <br /> IV. TYPEOF PERMIT: (Check only one box on line A. Check box on line B, if applicable) <br /> A) 1. ❑ New 2. Nr Replacement 3. ❑ Replacement of 4. ❑ Reconnecti n of 5. ❑ Repair of an <br /> System System ____-- Tank Only---------------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 ja Seepage Bed 21 ❑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 E. System Elev. 7. Final Grade <br /> Required (sq.ft.) Proposed (sq.ft.) (Gals/day/sq. ft.) (Min./inch) �(( // EI nal <br /> 110 -7Z $ z� �— 7 b Feet Feet <br /> VII. TANK Capacity <br /> INFORMATION In lions Total # of Pretab. ite Fiber- plastic Aper. <br /> g Gallons Tanks Manufacturer's Name Concrete un- Steel glass App. <br /> New E <br /> xisting ztr cted <br /> TanksSepOC Tank or Holding Tank <br /> Lift Pump Tank/Siphon Chamber El ❑ El E] 11 <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) Plumbe"Signature: mps) MP/MPRSW No.: Business Phone Number. <br /> �►FqR a 3 zG 266 <br /> PI m er's Address(Street,City,State,Zip Code <br /> 2 3S � s(�R LJi• 5 8 3 <br /> IX. COUNTY/ DEPARTMENT USE ONLY <br /> Disapproved Sanitary ermlt Fee II""°des cr`ePdweter ate Issue Iss in g nt Sigpture(N Stamps) <br /> Approved ❑Owner Given Initial u� <br /> to <br /> Adverse Determination <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SHP1398(R.OS/94) MTRIH01Il1N Originalfo Counl Y.One mpy To: SefetyB RuilJinge Diw:ion,Ocaner,Plui �, <br />