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f . <br /> Safety and Buildings Division <br /> " ■■+ SANITARY PERMIT APPLICATION Bureau 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 <br /> than 8 112 x 11 inches in size. U / J <br /> Sate Sanitary Permit Number <br /> • See reverse side for instructions for completing this application � P r Q� n <br /> The information you provide may be used by other government agency programs ❑Check it revision to previous application V } <br /> [Privacy Law,s. 15.04(1)(m)). State Plan LD.Number <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION <br /> prop rt Owner Name Property Location �^ <br /> 1/4 1/4,S sa 0 T 40 r N, R E(or <br /> Property Owners Mailing Address Lot Number Block Number <br /> CT. <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> J6. of 5 5 0 74 ( Cot7)456-?356 <br /> II. TYPE OF BUILD[ G: (check one) ❑ State Owned ❑ city Nearest Road <br /> C] Vd agefl <br /> ❑ Public 1 or 2 Family Dwelling- No.of bedrooms -3 town of AKL.A4 fLt)U4 <br /> III. BUILDING USE: (If building type is public,check all that apply) Parcel TaxNumber(S) <br /> 00W- <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 /> 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 /> New 2, Replacement 3. ❑ Replacement of 4, [:] E <br /> Reconnection of 5, ❑ Repair of an <br /> A) 1 ❑ <br /> System System Tank Only ____________ Existing System _________ -- System <br /> ----------------- <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 13. Absorp.Area 4. Loading Rate 5. Perc. Rate 6. System Elev. 7. Final Grade <br /> rO <br /> Required sq-ft.) Pro owed(sq.ft.) (Gals/day/sq. ft.) (Min./inch) Elevation <br /> `tomZ_ 117. 0 Feet19.157 Feet <br /> VII. TANK Capaelty Total #Of Prefab Site Fiber- plastic Exper <br /> in gallons Manufacturer's Name Con- Steel I <br /> INFORMATION New Existin Gallons Tanks concrete strutted glass APP <br /> Tanks Tanks <br /> fO El <br /> Septic Tank or Holding Tank 1000 100 � � ❑ [1 ❑ ❑ ❑ E] <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 Signature:(NoStamps) MP/MPRSWNcl Business Phone Number: <br /> Plumber's Name:(Pant) <br /> /c op irl5 JNf/iyryt gr 3�F IS- 66- 4157 <br /> umber's Address(Street, ity,State,Zip Coderl`Q <br /> ?_-7-7/,0 it � <br /> IX. COUNTY/ DEPARTMENT USE ONLY <br /> sd � t�n`1ndc'geI e water ate Issue Issuing Agent Signatur (N tam s) <br /> F]Dip{�roved Sanitary Permit Fe Surcharge e ) <br /> QgT <br /> proved r-1OwnerGiven Initial <br /> Adverse Determination <br /> X. CONDITIONS OF APPROVAL/ REASONS FOR DISAPPROVAL: <br /> SND-1(R.05194) DISTBIBUTIM Original to ly.One copy To: Safety B Buildings Div iaon,owner,Plumber <br />