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Safety and Building Div�sion <br /> SANITARY PERMIT APPLICATION Bureau Building Water Systems <br /> (E 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 a 6o 95 <br /> than 8112 x 11 inches in size. <br /> • See reverse side for instructions for completing this application State Sanitary Permit Number <br /> The information you provide may be used by other government agency programs ❑Check if revision to previous application <br /> [Privacy Law,s. 15.04(1)(m)]. State Plan I.D.Number / <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION S 6 — �11_5- <br /> Property Owner Name Property Location <br /> 1/4 1/4,5 Z$ T N, R I& E(or W <br /> Pro rtyOwner'sMaihng ddress � ®�?7/��i/ BI kNumb � <br /> City, tate Zip Code P ne Number Sub isio ' a /'or Ch9/1 NNur / 14116 <br /> I1. T PVillE OF ILDING: (check one) ❑ State Owned it Nearest Road <br /> age <br /> Public n 1 or 2 Family Dwelling- No.of bedrooms To of sW ISS MA/>J ST. <br /> III. BUILDING USE: (If building type is public,check all that apply) Parcel TaxNumber(s) <br /> a-AAVs - rq a - gy p_ ©<_3 700 <br /> 1 ❑ Apartment/Condo Z— £JH P• <br /> 2Assembly Hall 6 E] Medical Facility/Nursing Home 10 E] 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. ❑ New 2. 117(Replacement 3. ❑ Replacement of 4- ❑ Reconnection of 5. ❑ Repair of an <br /> System System ---- Tank Only .............Existing System -------- Exlsting5ystem <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 D1Seepage Bed 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 Per Day 2. Absorp.Area 3. Absorp.Area 4. Loading Rate S. Perc. Rate 6. System Elev. 7. Final Grade <br /> Z D Requ'red(sq.ft.) Propod od(sq.ft.) (Gals/ ay/sq.ft.) (Min./inch) Elevation <br /> 2 3 0 Feet <br /> VII. TANK Capacity site <br /> in gallons Total #of Manufacturer's Name Prefab. Con- Steel Fiber- plastic Exper <br /> INFORMATION New Exitin Gallons Tanks Concrete strutted glass />PP <br /> Tanks Tatl'� E ks ❑ ❑ El <br /> Septic Tank or Holding Tank C <br /> Lift Pump Tank/Siphon Chamber 0 ❑ El ❑ 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:(Prin ) Plumber's e:( Stamps) MP/MPRSW No.: Business Phone Number: <br /> tc F{>•t o�Kl nl 71.5. �e6- 5 <br /> Number's Address(Street,City,State Zip Code): <br /> Z w 35 1��ESSt2 <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> Dls00, <br /> a roved Sanitary Permit FP�e (Includes Groundwat,r ate ssue Issuing ent Signa re( St ps) <br /> ❑ pp SCJ Surcharge Fee) �j <br /> pproved ❑Owner Given Initial/ �d�Jag// <br /> Adverse Determination <br /> 0 4 <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> S110-639801 05/94) DISTRIBUTION: original to County.One copy To: safety&Buildings Division,owner,Plumber <br />