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� Y> <br /> Safety and Buildings Division <br /> �•i�iiitr• Bureau of Building Water System. <br /> v■■_nr■ SANITARY PERMIT APPLICATION 201E-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 County <br /> than 81/2 x 11 inches in size. <br /> • See reverse side for instructions for completing this application Stat�e(SSaamt-aa Permit Number` t� <br /> C'dOJcS <br /> The information you provide may be used by other government agency programs ❑Check it rev cion to previous application <br /> [Privacy Law,s. 15.04(1)(m)I. <br /> State Plan I.D.Number <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION <br /> Property Owner Name Property Location <br /> 14- /4 t/4,S i(3 T 9 ,N, R 1 E(or& <br /> Propert Ow�is Mailing Address Lot Number �\ lock Number <br /> City,State Zip Code (hone)umber Subdivision NamC rCSM Numh@r \� <br /> 1Z PauL .5 (6Q496-2321 l <br /> II. TYPE OF BUILDING: (check one) ❑ State Owned ':' City <br /> City Nearest Road <br /> Village <br /> El Public 1 or 2 FamilyDwelling- No. of bedrooms Town of 05 o <br /> Hl. BUILDING USE: (If building type is public,check all that apply) Parcel Tax Number(s) 1 <br /> 1 ❑ Apartment/Condo I <br /> 2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility <br /> 3 ❑ Campground 7 ❑ Merchandise: Sales/Repairs 11 ❑ Restau ant/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. X New 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an <br /> System System Tank Only Existing Syst m 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 W Seepage 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) _ Elevation <br /> 30o O 5 Feet S Feet <br /> Capacity VII INFORMATION in gallons Total #of Manufacturer's Name Prefab S e Fiber- Plastic Exper <br /> New ExIstin Gallons Tanks Concrete Steel glass App. <br /> stru ted <br /> Tanks Tanks A <br /> Septic Tanker V 0 ONE Wa:ime conc, Q ❑ ❑ ❑ ❑ <br /> Lift Pump Tank/Siphon Chamber I I I ❑ ❑ ❑ ❑ ❑ <br /> VIII. RESPONSIBILITY STATEMENT <br /> I,the undersigned,assume responsibility for installation of the onsite sewage system shown oi the attached plans. <br /> Plumber's Name:(Print) Plu a sSignature:(No Stamps) MP/MPRSWNo.: B usiness Phone Number: <br /> �'Pr r c Ci ° P v 7! - 5 <br /> Plumber's Address(Street,City,State,Zip Co e : <br /> 6 a 131ZOOKw: <br /> IX. COUNTY/ DEPARTMENT USE ONLY <br /> E]Disapproved Sanitary,Permit Fee Onaudes G,oundw4ter ate Issue Issui A ent Sig ore Stamps) <br /> A roved t1W�{1 Surcharge fee) <br /> pp ❑Owner Given Initial S _k-� <br /> Adverse Determination <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SHO-ti398(it.OV94) DISTIBUTI(1N. cir,.,n ,ln Cmi^ly.0ne<,,,F.. SJety B ft...d i,Di­,.,0.n,Dlum 11 <br />