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A <br /> Safety and ulldings Division <br /> SANITARY PERMIT APPLICATION Bureau of Building Water Systems <br /> 201 E.Washington Ave. <br /> In accord with ILHR 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 ,L,� 2 <br /> than 8 112 x 11 inches in size. /_ e ! / oC <br /> • See reverse side for instructions for completing this application State Sanitary Permit Number <br /> 3-;� 533 <br /> The information you provide may be used by other government agency programs ❑check it revision to previoils application <br /> [Privacy Law,s. 15.04(1)(m)]. State Plan I.D.Number <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION <br /> Property Ow er N$Knen / r Property Location e,.! <br /> U/C /`.A l S 1/4 1/4,5 �' T /Q ,N, RP/,:�' E (o <br /> Property Owner's Mailing Address Lot Number Block Number <br /> 8a a.✓ s705 / J 1 --- <br /> City,State Zip Code Phone Number Subdivislo Name oFGSm.dlum�er p / <br /> o e dl, /1I1575-115- c bl.�>sG� -677 ® � /l i e r-Side /l a•�re <br /> II. TYPE OF BUILDING: (check one) ❑ State Owned ❑ CityrA4,^ A./ <br /> arest Road <br /> Public 1 or 2 FamilyDwelling-No.of bedrooms '� C1 vowan of � d/ <br /> III. BUILDING USE: (If building type is public,check all that apply) Parcel Tax Number(s)c <br /> 1 ❑ Apartment/Condo 0v?o <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 /> 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. [5ir New 2_ ❑ Replacement 3_ ❑ 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 []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 S. Pert. Rate 6. System Elev. 7. Final Grade <br /> Required q(sq. ft.) Proposed(sq.ft.) (Gals/day/sq. ft.) (Min./inch) Elevation <br /> y�/ ,� .. �� Feet Q2. >9' Feet <br /> Capacity <br /> VII. INFORMATION in gallons Total #of Manufacturer's Name Prefab. Site Con- steel Fiber- plastic Exper <br /> New ExIstin Gallons Tanks Concrete strutted glass App. <br /> Tanks Tanks E <br /> Septic Tank or 6h&k4 tIaajs_ SQ Sd ,,,/ �.1r ❑ ❑ ❑ ❑ ❑ <br /> I Ift 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:(N Stamps) MP/MPRSW No.: Business Phone Number: <br /> 5X01 <br /> Plumber's Address(Street,City,State,Zip Code): <br /> ,r3a� �'l .S lit �� 6-✓ Sig 7 <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑Disapproved Sanitary Permit Fee (Includes Groundwater ate Issue Issuing A Signat re( S ps) <br /> � I� Surchargelee)10,40/proved ❑Owner Given Initial jv"��/1 <br /> Adverse Determination <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SHO-6398(H.05/94) OISTBIBUTION: Original to(nar,f y,One ropy To: Su Fely&BuilJim3s❑imvpn,Owner,PIumLer <br />