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1AP4 u f l 4 / ety and Buildings Division <br /> wr�a�s Bureau of Building Water Systems <br /> - --\.171.2._ r• SANITARY PERMIT APPLICATION 201 E.Washington Ave. <br /> 4. In accord with ILHR 83.05,Wis.Adm.Code P.O.Box 7969 <br /> Madison,WI 53707-7969 <br /> • Attach complete plans(to the co my o,� •.� 4for`the system,on paper not less county / <br /> than 8 1/2 x 11 inches in size. 'J t t, a-.-Ni OSl?j i�1ci '� �►�}rt — ! * <br /> 10 1 State Sanitary Permit Number 73 <br /> • See reverse side for instructions f r complete t f a•plication //O 7Q <br /> The information you provide may be used by other governmen agency programs ❑Check it erosion to previous application <br /> 'Privacy Law,s. 15.04(1)(m)]. State Plan I.D. er <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION 75-9` <br /> Property Owner Name l Property Location <br /> (j-A,(` 6.-r,c Rs e7/0 A)F1/4/ J 1/4,S J3 TJ? ,N, R )7 E(or / <br /> Property Owner's Mailing Adesl) /� Lot Number Block Number <br /> O`� co, G dry) e�� ^` <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> 0e4 S'fe-r •(),rYg9 ( )766440g'Y02 <br /> II. TYPE OF BUILDING: (check one) ❑ State Owned ❑ City c Nearest Road <br /> ❑ Village / % ) / <br /> Public 1 or 2 Family Dwelling- No.of bedrooms Town OF 4/4)C0//t./ Co, Rot <br /> III. BUILDING USE: (If building type is public,check all that apply) Parcel Tax Number(s) <br /> 1 ❑ Apartment/Condo e/ : 35133 0/ 'OCD <br /> 2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility <br /> 3 ❑ Campground 7 El Merchandise: Sales/Repairs 11 0 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. iNlew 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an <br /> ystem 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 ❑Holding Tank <br /> 12 RI Seepage Trench 22❑In-Ground Pressure 1 42❑Pit Privy <br /> 13❑Seepage Pit /A x ari�r'.¢�`ar- ) 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 /> OR ao Required (s f .) Proposed(sq`. .) (Gals/ sq.sq.f .) (Min./inch) en Elevation <br /> ` a �(p(O`�O 'mob , r . / ! 2 Feet Feet <br /> Capacity <br /> VII. TANK in Ca g gallons Total #of Prefab. Site Fiber- Plastic Exper. <br /> INFORMATION Gallons Tanks Manufacturer's Name Concrete Con- Steel glass App. <br /> New Existing strutted <br /> Tanks Tanks / <br /> Septic Tank or lrlr Tarilc V / / �j49-e1-') ❑ ❑ ❑ ❑ ❑ <br /> t ift Pump Tank/Siphon Chamber ❑ ❑ El ❑ 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:(Pb int) Plumber's Signature:(No Stamps) MP/MPRSW No.: Business Phone Number: <br /> A-ca✓� I1 y�S /.�r) I. e. 4 c7.7‘ _ yY-x--276' <br /> Plumber's Address(Street,City,State,Zip Code): <br /> we A'' S'1" 5 It- e, e:44.4-- -s-c'7,,, <br /> IX. COUNTY/ DEPARTMENT USE ONLY <br /> ❑Disapproved Sanitaryyy Permit Fee (ndudesGroundwater Date Issued Issuing A nt Si.-at��A.Stamps) <br /> j50 urcharge F ee) /� <br /> "�Rpproved 111 Owner Given Initial / Q� o f �. <br /> Adverse Determination /O'L / <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br />