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Safety and Buildings Division <br /> SANITARY PERMIT APPLICATION 201eF Wa hingtonAveerSystems <br /> In accord with ILHR 83.05,Wis.Adm.Code P.O.Box 7969 <br /> Madison,WI 53707-79 9 <br /> • Attach complete plans(to the county copy only)for the system,on paper not less County <br /> than 8 1/2 x 11 inches in size. �/jV `t(O <br /> • See reverse side for instructions for completing this application State Sanitary Permit Number <br /> lslo to <br /> The information you provide may be used by other government agency programs Elchec d viswn o previous application <br /> [Privacy Law,s. 15.04(1)(m)L State Plan .D.Number <br /> L APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION ao&�o <br /> Property Owner Name Property Location <br /> SO ," 1/4 1/4,Sv7 T_37 ,N, R/yE(or9 <br /> Proper Owner's Mailing Address Lot Number Block Number <br /> 0 , Q o 7 SL <br /> City,Stat i ZI Code Phone Number So6dtv*ewAlame or CSM Number <br /> G�c���� c r.✓ Y93 7 ( J.17-e/a-2 V / X33 ' S? <br /> II. TYPE F BUILDING: (check one) ❑ State Owned t Nearest R ad <br /> �7 ❑ vilya e <br /> Public 1 or 2 FamilyDwelling- No. of bedrooms 42 own OF / e//e_ L1Cl�e eo,c,/ k-ri <br /> III. BUILDING USE: (If buildmgtypeispublic,checkallthatapply) Parcel TaxNumber(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 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 41OHolding 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 13. Absorp.Area 4. Loading Rate 5. Perc. Rate 6. System Elev. 7. Final Grade <br /> 02 Required (sq. ft.) Proposed(sq.ft.) (Gals/day/sq. ft.) (Min./inch) Elevation <br /> -� Feet Feet <br /> VII. TANK Capacity site <br /> INFORMATION in gallons Galltal ons Tanks Manufacturer's Name Concrete Con- steel glass PFiber- lastic Appr <br /> New Existin strutted <br /> Tanks Tanks <br /> Septic Tank or Holding Tank OLb <br /> t ift Pump Tank/Siphon Chamber El ❑ IJ ❑ El <br /> 171 <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 Na e:(Pr t) Plumber's Signature: oStamps) MP/MPRSW No.: Business Phone Number: <br /> Plumber's Address(Street,City,State,Zip Code): <br /> O S"-/ 5 i/' e til G✓� s�� .Z <br /> IX. COUNTY/ DEPARTMENT USE ONLY <br /> E]Disapproved Sanitary Permit Fee (I ndchargeoundwa[er ate Issue lissuingA nt Si Hato a oStamps) <br /> Surcharge Fee) <br /> proved ❑Owner Given Initial <br /> Adverse Determination <br /> X. CONDITIONS OF APPROVAL/ REASONS FOR DISAPPROVAL: <br /> }�,epbcPL &,n I ►ssi t�� )0-a I-o� <br /> SHO-6398 ht 05/94) DISTRIBUTION. original to eoCudy,One Copy To: Sntety 8 Buildings Divn-on,Owneq Plumbar <br />