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/ <br /> A# . Safety and Buildings Division <br /> �■Zr>. rfi SANITARY PERMIT APPLICATION Bureau of Building Water System <br /> 201 E.Washington Ave. <br /> In accord with ILHR 83 CIS,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 H 5:;Zthan 8 12 x 11 inches in size. u <br /> mar <br /> • See reverse side for instructions for completing this application StateSanitary Permit Number <br /> t7 767" <br /> The information you provide may be used by other government agency programs ❑Check it revision to previous application <br /> IPrivacy Law,s. 1504(1)(m)). State Plan LD Nu ber <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION sq�-a63i�y <br /> Property Owner Name Property Location <br /> LEW us 0 1f4 1/4,S 36 T 40 ,N, R 14 E(oro <br /> Property Owner's Mailing Address Lot Number <br /> 2 3 1 r1p Ro- R2. <br /> City,Sfate Zi CoeqPhone Number Subdivisbn Name or CSM Number <br /> 40 !! Q 15 ) -T)W & 0&NA09S LK, APD <br /> IT. TYPE OF BUILDING: (check one) ❑ State Ownedity Nearest Road <br /> C3 <br /> Village OAK 9D <br /> Public 1 or 2 FamilyDwelling- No. of bedrooms 2Iiii Town of <br /> III. BUILDINGUSE: (If building type is public,check all that apply) Parcel Tax Number(s) <br /> 1 ❑ Apartment/Condo 74) <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. ❑ New 2. t4 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.Wolding 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(sq.ft.) Proposed(sq.ft.) (Gals/day/sq. ft.) (Min./inch) Elevation <br /> Feetj Feet <br /> TANK Capacity <br /> VII. INFORMATION in gallons Total #of Manufacturer's Name Prefab Con- Steel Fiber- plastic Exper <br /> New Existin Gallons Tanks Concrete glass App. <br /> Tanks Tanks .f` strutted <br /> Septic Tank or Holding Tank OD �� xvivo Z L ❑ ❑ ❑ ❑ ❑ <br /> Lift 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: No amps) MP/MPRSWNo.: Business Phone Number: <br /> I a4mc nP s ( 3�f26 IS- 866- I{/s� <br /> Plu ber's Address(St City,State,Zi ode): <br /> 7 D JS 1�55WJZ W1. SYSJ3 <br /> IX. COUNTY/ DEPARTMENT USE ONLY <br /> ❑Disapproved Sanitary Permit Fe ondudes Groundwater ate ue Issuing Ag tsi atur Stamps) <br /> Approved ❑Owner Given Initial C Surcharge tee) (O <br /> Adverse Determination / v <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> Se0-6398 or DSNn) DISTa1aUTION: Original to Coura ,One ropy To: Sure,,6 auildingn Dnn,,.n,Owner,Plumber <br />