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_'� � , <br /> Cn)-I <br /> ff 1;` Safety and Buildings Division <br /> ' r SANITARY PERMIT APPLICATION g Water Systems <br /> Bureau of Buildin <br /> 201 E Washington Ave. <br /> In accord with[LHR 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 <br /> than 8 112 x 11 inches in size. <br /> • See reverse side for instructions for completing this application Sta a Sanitary Permit NLImber <br /> The information you provide may be used by other government agency programs E]Check it 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 AM- <br /> Prope y Owner Name Property Location <br /> t%_ � 1/4,S + T� N, R 4. E(or@ <br /> Propert 7,7 er's Mallin Address Lot Number ��, I Block Number <br /> Z4 � �/-J <br /> C Staterrt <br /> ( . Ph u er Subdivisi m <br /> Naeor CSM Number <br /> 4ESS y 1. rn Zi Code 35 � ( e�i R 4 S <br /> II. TYPE OFBUILDING: (check one) ❑ State Owned 71 it( Nearest Road <br /> Public 1 or 2 FamilyDwelling- No.of bedrooms D Town or SC6T p 64 <br /> III. BUILDING USE: (If building type is public,check all that apply) Parcel TaxNuumbber(s) /r[ <br /> 1 ❑ Apartment/Condo d` J 411 <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. W 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 /> 1 1�Seepage Bed 21 E]Mound 30 E]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.) Proposesq.ft.) (Gals day/sq. ft.) (Min./inch) e a levation <br /> Q� 72. 1 Feet .� Feet <br /> VII. TANK Capacity <br /> in gallons Total #Of Prefab. SiteLEO <br /> Fiber- Ex er <br /> INFORMATION Gallons Tanks Manufacturers Name Concrete Con- Plastic p <br /> New Existing struttedglass App. <br /> Tanks Tanks <br /> Septic Tank or Holding Tank Z1 R 0 n 1:1 ElLift Pump Tank/Siphon Chamber ❑ 1 ❑ <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) 'lumber'sSignature: No mps) MP/MPRSW No.: Business Phone Number: <br /> &C �s `�,t 342671S, <br /> PI mber's Address(Street'C Gt ,State,Zip Code): <br /> 2-10760 3S ti. "01a Al. S SR3 <br /> IX. COUNTY/ DEPART ENT USE ONLY <br /> E]Disapproved Sanitary Permit ee (includes Groundwater I Date Issued IIssuin A nt Si at a Stamps) <br /> A roved Surcharge lee) <br /> pP ❑Owner Given Initial I/+�- tr <br /> Adverse Determination �� � �� /J <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBn'6398(H.05/94) DISTRIBUTION. Original to Cnuni y,One ropy To: Sefety 8 Buildings Divcion,Owner,Plumber <br />