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\ DJ 1 t::-Q/J-D Safety and Buildings Division <br /> �•Gri SANITARY PERMIT APPLICBureau 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 /> 0 Attach complete plans(to the county copy only)for the system,on paper not less count / <br /> than 8 112 x 11 inches in size. u.Y►-lam Jr <br /> � <br /> 3 l0 —J <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 E]Check it revision to previous applil'tion <br /> [Privacy Law,s. 15.04(1)(m)]. State Plan I.D.Number <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION <br /> Property Owner Name Property Location <br /> zwYZCr <br /> .5F 1/4 5p_ 1/4,S Ze T 3V ,N, R/.f E (orls <br /> Property Owner's Mailing Address Lot Number Block Number <br /> 6 <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> uoX& l6/ 7/ ( iS)A4B 7106 <br /> II. TYPE OF BUILDING: ((heck one) ❑ State Owned ❑ cty Nearest Road <br /> ❑ Village <br /> Public 1 or 2 Family Dwelling-No.of bedrooms j own OF e <br /> III. BUILDING USE: (if buildingtype ispublic,check allthatapply) Parcel TaxNumber(s) <br /> 1 ❑ Apartment/Condo 00$-212.$-6z-700 <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_ 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 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) ,t.!j rXI, Elevation <br /> A150 G}0O fe0 . $ /71641`106 �.O Feet gj'D Feet <br /> Ca acit <br /> VII INFORMATION in allons Total #of Prefab. Site4tee <br /> iber- Exper <br /> g Gallons Tanks Manufacturer's Name concrete con- lass Plastic App <br /> New Existingstrutted <br /> Tanks Tanks <br /> Septic Tank orlieltng-Fank p0 000 0 <br /> lift Pump Tank/S to DO I G 00 <br /> VIII. RESPONSIBILITY STATEMENT <br /> I,the undersigned,assume responsibility for instal An of the onsite sewage system shown on the attached plans. <br /> Plumber's NME`g�t IL TESTING PI e�Signaturtamps) PRS 871 Will 24531 KING ROAD <br /> Plumber's Ad r"0 - -cI4111111- -9 <br /> Statr ode): <br /> fIC r 79 <br /> V15) 468=4010 <br /> IX. COUNTYV DEPWITTIlil USE ONLY <br /> ❑Disapproved Sanitary Permit Fee (includescround.aler ate's <br /> Issuing Ag ntSi nature( Stamps) <br /> roved harge ree) L-1"5'e' <br /> pp ❑Owner Given Initial /J <br /> Adverse Determination <br /> X. CONDITIONS OF APPROVAL/REASONS FORDISAPPROVAL: <br /> V-) -7)v\ <br /> SHO-6398(N.W94) DISTRIBUTION Original u)Cour,ly,One copy To: Safely 8 Buildings Dim-ton.owner,Plumber <br />