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or)C" , <br /> (9) <br /> afetya,"BuildingSANITARY PERMIT APPLICATION Bureau of Building Water Systems <br /> 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 County <br /> than 8 trz x 11 inches in size. gor ?,l- <br /> • See reverse side for instructions for completing this application State Sanitary Permit Number <br /> The information you provide may be used by other government agency programs ❑Check if revision to previous application 1 n <br /> [Privacy Law,s. 15.04(1)(m)]. State Plan I.D.Number V I <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION <br /> Property O ner Name Property Location <br /> i` C `„ �A1 Uj1/4 � 1/4,S T37 ,N, R /J iV(or W <br /> 9 <br /> Property Owner's Mai ng Address Lot Number Block Number <br /> Ql p� SG�0{^,Q B C A4 <br /> CI ,I State Zip Code Phone Number Subdivision Name or CSM Number <br /> (3r o,.i7�s %+ r- (A-) i I(*/x,)y6 f- /s' C Ym M //2 n (-i 3 <br /> 11. TYPE OF BUILDING: (check one) ❑ State Owned ❑ city Nearest Road, <br /> ❑ Village / <br /> Public 1 or 2 FamilyDwelling-No.of bedrooms 3 Town or 71 / a� �Q vti 7� <br /> III. BUILDING USE: (If building type is public,check all that apply) Parcel TaxNumber(s) <br /> 03Y- 45 'a _ 033 � s- <br /> 1 ❑ Apartment/Condo <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. g New 2. ❑ Replacement 3. ❑ Replacement of 4_ ❑ Reconnection of 5. ❑ Repair of an <br /> System System ------------- Tank Only_ __- -_____ Existing System ___ _ExistingSystem <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 21O 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: //ar ld 4% k-FIV /S's'/ <br /> 1.Gallons Per Day 2. Absorp.Area 3. AbsopgXrea 4. Loa i a1 5. Perc. Rate 6. System Elev. 7. Final Grade <br /> Required (sq. ft.) Proposed(sq.ft.) (Gals/day/sq. ft.) (Min./inch) / Elevation <br /> 7/3-6 �l ,/A .� . Y le6.6.- Feet �e 9a Feet <br /> VII. TANK Capacity Site <br /> in gallons Total #Of Manufacturers Name prefab. Con- Steel Fiber- plastic Aper. <br /> INFORMATION Gallons Tanks concrete glass App <br /> New Existin strutted <br /> Tanks I Tanks <br /> Septic Tank or Holding Tank Y /00 U h'/W ❑ ❑ ❑ ❑ <br /> 1-1 <br /> El <br /> I ift Pump Tank/Siphon Chamber G 7a 0 D El 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) Plumber's Si atu :(No Sta s /MPRSW No.: TBusiness Phone Number: <br /> 7/17 <br /> Plumber' ddress(Street,City,State,Z/Code): l e .5- V ^S3 <br /> IX. COUNTY/ DEPARTMENT USE ONLY <br /> ❑Disapproved Sanitary Perml ee (I Surcharge I eeCwater ate sue IssuingA ent Sign lure N tamps) <br /> ISP /Surcharge fee) 4 <br /> Approved F1 Owner Given Initial ✓/ `r <br /> Adverse Determination <br /> X. CONDITIONS OF APPROVAL/REASONS F SAPPROVAL: <br /> SND-6398(x.05/94) DISTRIBUTION: original to County,One(a Py To. safety&Ruiblinge Divi--ion,Owner,Plumber <br />