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Safety and Buildings Division <br /> ��■�,ir.n SANITARY PERMIT APPLICATION Bureau of Building Water System <br /> In accord with(LHR 83.05,Wis.Adm_Code 201 E.Washington AveP.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 R <br /> than 8 112 x 11 inches in size. <br /> 15 <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 " <br /> ❑Check it revision to previous aZication <br /> (Privacy Law,s. 15.04(1)(m)]. P <br /> State Plan I .Number <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION <br /> Pr rty Owner Nam Property Location <br /> !Cq4k � C'fIL D4/��7t`�� 44 142,,� 1+,S � T N, R 1 7 E(o W <br /> Property Owner's Mailing Addre Lot Number Block Number <br /> Ci ,State Zip Code Phone Number Subdivision Name or CSM Number <br /> A ' /qps ,0/j , OI2 244W—ZYK0 4 5 - 4-L P. 15—,6-15-7 <br /> II. TYPE F BUILDING: (check one) ❑ State Owned !' ❑ city Nearest Road <br /> Public 1 or 2 Famil Dwellin - No.of bedrooms � E' Village <br /> tyllown OF ull� <br /> !II. BUILDING USE: (if buildingtype is public,check all that apply) Parcel TaxNumber(s) <br /> 1 ❑ Apartment/Condo 's <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 online B, if applicable) <br /> A) 1. C&New 2. ❑ Replacement 3- ❑ Replacement of 4- ❑ Reconnection of 5. ❑ Repair of an <br /> ______ ystem System TankOnl <br /> y--------------- <br /> ____ __ Existing System Existing System <br /> B) A Sanitary Permit was previously issued. Permit Number ' 53 Date Issued —a <br /> V. TYPE OF SYSTEM: (Check only one) <br /> Non-Pressurized Distribution Pressurized Distribution Experimental Other <br /> 11 2QSeepage 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 6. System Elev. 7. Final Grade <br /> Required(s(sq. ft.) Proposedlq.ft.) (Gals/day/sq. ft.) (Min./inch) Elevation <br /> c86r% <br /> r / �6• Feet 9 Feet <br /> VII. TANK Capacity <br /> INFORMATION in gallons Total #of Prefab. Site Fiber- Exper. <br /> Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App <br /> New Existin strutted <br /> Tanks <br /> Tanks <br /> Septic Tank or Holding Tank IW6 /G1�,9 �il�tS�» _ ❑ <br /> Lift Pump Tank/Siphon Chamber o ❑ El <br /> VIII. RESPONSIBILITY STATEMENT <br /> I,the undersigned,assume responsibility for installation of the onsite sewage system shown on the attached plans. <br /> Plu s Name:(Print) Plu r a e' No am ) MP/MPRSW No.. Business Phone Number: <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 67 <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> [—]Disapproved Sanitary Fe (includes Groaadwacer iZ6 <br /> issuing 71 A en <br /> �1LtiNprOVed Is`/// Sur<harye ree) <br /> \�V ❑Owner Given Initial ,� <br /> Adverse Determination <br /> X. CONDITIO S OF APPROVAL/REASONS FOR DISAPPROVAL. <br /> 2 <br /> E' U.2rl" <br /> SND-1,398(R.OS/y4) DISTRIRUTION: Original to(aunty,One ropy To: salety 8 Ruiidinys nivn.ion,Owner,Plumber <br />