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icii <br /> : AR SANITARY PERMIT APPLICATION SafetyandBuildings aterSy <br /> Bureau of Building Water System <br /> 201 E.Washington Ave. <br /> In accord with LHR 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 1/2 x 11 inches in size. ug aqQ 8 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]Che revision to[porev_ilou/s/application <br /> (Privacy Law,s. 15.04(1)(m)]. State Plan I.D.N /`�er p <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION 7" ( �� <br /> Propert wner N e Property Location <br /> 1/4 1/4,S Z , T qQ ,N, R 17 E (or)(W) <br /> Property Owner's Mailing Address Lot Number Blo k N er <br /> CuNTorl AV. S. 2 <br /> Cit ,State Zip Code Phone Number Subdivision Name or CSM Number <br /> wOMIa tj Mt.) . <br /> rd • SS Lf zo ( I2.) 8- 07/65 Von. 12- P. 8 <br /> II. TYPE OF BUILDING: (check one) ❑ State Owned ❑ City Nearest Road <br /> ❑ village (A !1 O� R Pr. <br /> Public 1 or 2 FamilyDwelling- No.of bedrooms Town of 1V <br /> III. BUILDING USE: (If building type is public,check allthatapply) Parcel�Tax Number((ss) <br /> 1 E] Apartment/Condo 036 gg7_3 05 q70 <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 /> q) 1. New 2- ❑ Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an <br /> System System Tank Only Existing System Existing System <br /> ------------------------------------------------------------------------------------------------ <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 PerDay 2. Absorp.Area 3. Absorp.Area 4. Loading Rate 5. Perc. Rate 6. System Elev. 7. Final Grade <br /> Required(sq. ft.) Pro osed(sq.ft.) (Gals/day/sq. ft.) (Min./inch) Elevation <br /> 3�7j 376 1 . ZLf <br /> 9-7.6 Feet 19, $$ Feet <br /> Capacity <br /> VII. TANK in gallons Total #of Prefab. Site Fiber- Exper <br /> INFORMATION Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App <br /> New Existin strutted <br /> Tanks Tanks <br /> Septic Tank or Holding Tank 10001 1000 ❑ ❑ ❑ ❑ ❑ <br /> Lift Pump Tank/Siphon Chamber, 40(D ❑ ❑ ❑ ❑ ❑ <br /> VIII. RESPONSIBILITY STATEMENT JL <br /> 1,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 amps) MP/MPRSW No.: Business Phone Number: <br /> Ai c R �� S - f X57 <br /> PI mber's Address(Street,City,State,Zip Code): <br /> IX. COUNTY/ DEPARTMENT USE ONLY <br /> ❑Disapproved Sanitary PermitFe�ar-:;eseroundwacer ate ssue suing Agent Si nature(I a s) <br /> pproved ❑Owner Given Initial ,� (� u narge Fee) /� <br /> Adverse Determination " v /Gf— gl <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(R.05/94) DISTRIBUTION: Original to County.One copy To: Safety&Ruildings niuuion,Owner,Plumber <br />