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_ Safety and Buildings Division <br /> ^��```��� SANITARY PERMIT APPLICATION Bureau BuildingWater Systems <br /> tr3201 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 1/2 x I I inches in size. s teSanitary Permit Number <br /> • See reverse side for instructions for completing this application �II®� <br /> The information you provide may be used by other government agency programs ❑Che�PrcNision to previous application <br /> (Privacy Law,s. 15.04(1)(m)I. State Plan I.D.Numb <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION <br /> Prope Owner Name �+property Location <br /> 1 C �%S 2 T � N R IS E(or <br /> P4gState <br /> rtOwner's Mailing A dress Lot Number Block Number <br /> Zi de one Number Subdivision Name or CSM Number <br /> F BUILDING: (check one) ❑ State Owned°' it� Nearest Road <br /> Public 1 or 2 FamilyDwelling- No.of bedrooms <br /> 3 ❑ Town DF s^-s�/0� <br /> III. BUILDING USE: (If building type is public,checkallthatapply) Parcel TaxNumber(s) <br /> 1 ❑ Apartment/Condo /Z +ZZ(c bZ 100 <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 ❑ 12 Mobile Home Park ❑ 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 ❑ New 2.r Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an <br /> System __System _ Tank Only --- Existing System -- Existing System <br /> -------y---------- p Y <br /> B) ❑ A Sanitary Permit wa�r6vlousl 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 /> 7. 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.) Pro osed(sq.ft.) (Gals/ray/sq.ft.) (Min./inch) Elevation <br /> 3 6S q 7•S Feet /01>. d Feet <br /> VII. TANK Capacity Site <br /> INFORMATION in gallons Total ons Tanks Manufacturer's Name Conc Prefab. <br /> Con- Steel glass Plastic APp' <br /> New Existin strutted <br /> Tanks Tanks ! J <br /> Septic Tank or Holding Tank OOo O400 a ® F1 Q F] El El <br /> Lift Pump Tank/Siphon Chamber ❑ ❑ ❑ ❑ ❑ El <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:( o amps) MP/MPRSW No.: Business Phone Number: <br /> o K14J d .3�'� <br /> PI tuber's Address(street,City, tate,Zip Code): <br /> 17 <br /> 1 I bo w 3S �AS1'ER L�1 . 54893 <br /> IX. COUNTY/ DEPART NT USE ONLY <br /> Disa roved Sanitary Permit Fee imiudC5Gr,oandwater F;ate susue IssuingA entSignature oStamps) <br /> ❑ pp y-�s�surcharge lee) <br /> Approved ❑Owner Given Initial 50. W T <br /> Adverse Determination J <br /> X. CONDITIONS OF APPROVAL/ REASONS FOR DISAPPROVAL: <br /> �%s��raf���- rerru� iJeev �"Ycv,�les <br /> SRO-6398(R.05/94) DiSTRIaOTION: Original to rufudy,One Copy Ta: safety&Ruildings Dimuon,owner,PlumkKr <br />