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Safety and Buildings Division <br /> --- SANITARY PERMIT APPLICATION Bureau of Building Water Systems <br /> ._.•�n-•ttrt 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 Coun <br /> than 8 112 x 11 inches in size. u "o t_ <br /> • See reverse side for instructions for completing this application State Sanitary Permit Num er <br /> Sol�-7y <br /> The information you provide may be used by other government agency programs ❑Check it revision to previous application <br /> [Privacy Law,s- 15.04(1)(m)]. State Plan LD.Number <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION <br /> PropXtyowner ame Property Location <br /> lu 14L e 1/4 1/4,S/0 T `// N, R /�E(or W <br /> Pro errtty06�is Mailing Address`c [ ` C�e L,c"umbP;G .� Block Number <br /> /Nt� <br /> City,State Zip Code Phone Number ubdivision Name or CSM Number <br /> Q/ 4:0 ss 3/ 1(61,;? — <br /> II. TYPE BUILDING: (check one) ❑ State Owned ` � City f Nearest Road <br /> Public 1 or 2 FamilyDwelling-No:of bedrooms 3 ❑ rowan OF-5 �✓�'-5-5 yd33 ;Oee%o+ LKS <br /> III. BUILDING USE: (If building type is public,check all that apply) Parcel TaxNumber(s) <br /> 1 ❑ Apartment/Condo 1 0a 5a/,P 0 / a 0 6 <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. [X 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 JASeepage 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 (sq. ft.) Proposed(sq.ft.) (Gals/day/sq. ft.) (Min./inch) 17,4 <br /> Elevation <br /> 1150 Feet Feet <br /> Ca acct <br /> VII INFORMATION in gallon$ Total #of Prefab. site Fiber- Plastic Exper. <br /> Gallons Tanks Manufacturer's Name Concrete Con- Steel glass App. <br /> New Existin strutted <br /> Tanks Tanks <br /> Septic Tank or Holding Tank Qt/ e—& ❑ ❑ ❑ ❑ ❑ <br /> Lift Pump Tank/Siphon Chamber I t ❑ ❑ ❑ ❑ ❑ ❑ <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 Na e:(Prin � Plumber's Signature: Stamps) MP/MPRSW No.: Business Phone Number: <br /> a116 7 <br /> Plumber's Address(Street,City,State,Zip 04de): / <br /> F7 < .5—/ S//- e/ <br /> IX. COUNTY/ DEPARTMENT USE ONLY <br /> ❑Disapproved Sanitary Permit Fee (l.duaeseroundwater ate Issue Issuing Agen Signat re mps) <br /> rOVed urcharge tee) <br /> pp ❑Owner Given O� �l9172/ Is <br /> Adverse Determination <br /> X. CONDITIONS OF APPROVAL/ REASONS FOR DISAPPROVAL: <br /> SHU-6398(H.05/94) MTBIBUTION. Original to Caur,t y,One copy To: Safety 8 Buit4lings Dlviceon,Owner,PlurnWr <br />