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r Safety and t �ings D / <br /> ■ ■■■'• <br /> SANITARY PERMIT APPLICATION Bureau of Building Water System: <br /> �G�r�r• <br /> 201 E.Washington Ave. <br /> In accord with ILHR 83 05,W is.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 inot less county �rr+ <br /> than 8 1/2 x 11 inches in size. ltRp1E([ <br /> • See reverse side for instructions for completing this application State Sanitary <br /> �PemmmitNumber <br /> The information you provide may be used b other government agency programsCheck <br /> � � ' <br /> y p y y 9 9 y p g ❑Ch kit revision to previous application <br /> [Privacy Laws. 15.04(1)(m)l. State Plan 1.D.Number <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATI ON I <br /> Property Owner Name Prop rty Location <br /> 908 percIZSOIJ 111 1/4 5E 1/4,S Zy T41 ,N, R 1b E (or W <br /> Proper t Owner's Mailing Address Lot Num er Bigek-Mvrnber <br /> iSs l-iNo s AUeEs <br /> City,State I Zip Code Phone Number Subdivision Name or CSM Number <br /> R E o1" Sr.CROtx MN S50•}� (W7- 3-3287 <br /> II. TYPE F BUILDIN : (check one) ❑ State Owned ❑ cityy Nearest Road <br /> ❑ villag 51055 OW6/L RrJ. <br /> Public 1 or 2 Family Dwelling- No.of bedrooms 3 Town F <br /> III. BUILDING USE: (If building type is public,check all that apply) Parcel Ta Number(s) <br /> 1 F1 Apartment/ Q3'a. ��°� T );L _ <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 , if applicable) <br /> A) 1_ XNew 2. ❑ 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 /> NonPressurizedDistribution Pressurized Distribution 'Experimental Other <br /> 11,KSeepage Bed 21 ❑Mound 130❑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-[n-Fill <br /> VI. ABSORPTION SYSTEM INFORMATION: <br /> 1. Gallons Per Day 2- Absorp.Area 3. Absorp.Area 4. Loading Rae 5. Perc. Rae 6. System Elev. 7. Final Grade <br /> qRe�]uIred(sq. ft.) Proposed(sq.ft.) (Gals day/sq. .) (Min In ) G levation <br /> -1 I/3 (p`rg t Z •� Feet s•q Feet <br /> VII. TANK Capacity <br /> n allons Total #of Prefab Site Fiber- Exper <br /> INFORMATION g Gallons Tanks Manufacturerf's Name Concrete con- steel glass Plastic App <br /> New Existin strutted <br /> Tanks Tanks <br /> Septic Tank or Holding Tank 000 1000 pvJ ❑ ❑ ❑ ❑ I ❑ <br /> Lift Pump Tank/Siphon Chamber ❑ ❑ ❑ ❑ I ❑ I ❑ <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 mps) M /MPRSW No.. Business Phone Number: <br /> c+IH4n ,Ns •«•d `� 5. 866 ,5 <br /> Plumber's Address(Street,City,State,Zip Code): <br /> Z7 60 w 3S l��ssrriz WI•i ,g893 <br /> IX. COUNTY/ DEPARTMENT USE ONLY <br /> E]Disapproved Sanitary Permit Fee II"dudes croundwarer ate s7�c <br /> suingA nt Si nat r oStamps) <br /> roved r,�,s�rmarye ree) <br /> 1pp ❑Owner Given Initial / n Adverse Determination l �O 00 `it <br /> X. CONDITIONS OF APPROVAL/ REASONS FOR DISAPPROVAL; <br /> W16398(R.05194)�DKTBIBUTIUN: Original l"Caum Y.Urge coPY To: Se)e1�Nuildinge nivui"n.Oweer,Vlumbz, <br />