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_a, - n , <br /> 'ii <br /> Safety and Buildings Division <br /> SANITARY PERMIT APPLICATION 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 81/2 x 11 inches in size. <br /> • See reverse side for instructions for completing this application State Samtay rmrt Nu mber���, IC�� <br /> � Iql 3 <br /> The information you provide maybe used by other government agency programs El Check it re ilio o previous application <br /> (Privacy Law,s. 15.04(1)(m)I. State Plan I.D Number <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION S <br /> Prope wner Nam Property Location <br /> ( 1/4 1/1 T N, R E(or <br /> Propert Owner's Mailin Address Lot Number 7 Block Number <br /> City,State Zi Code Ph ne Number Subdivism Nameor CSMNumber <br /> Ma <br /> S 2S • acG Su460, <br /> H. TYPE F B I DING: (check one) ❑ State Owned oIt Nearest Road <br /> . - <br /> ❑ Public 1 or 2 Famil Owellin ❑ Villa- No. of bedrooms Z Townge of s /^/9 OG6 !JV/. <br /> III. BUILDING USE: (If buildingtype lspubhc,check all Rhatapply) Parcel Tax Number(s) <br /> 1 F-1 Apartment/Condo R g- a5- a3' <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 q ❑ Reconnectionof 5 E] Repair of an <br /> System "`System Tank Only Existing System 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 ❑Seepage Bed 21 ❑Mound 30❑Specify Type 41 ❑ Holding Tank <br /> 12❑Seepage Trench 22,4!§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.Area3. Absorp.Area 4. Loading Rate 5. Perc, Rate 6. System Elev. 7. Final Grade <br /> Required (sq. ft.) Pro sed(sq. ft.) (Gals/day/sq. ft.) (Min./inch) Elevation <br /> 30 Z it 3Z Feet Im.G3-Feet <br /> TANK <br /> Ca aat <br /> VII. INFORMATION in gallons Total #of Manufacturers Name Prefab SI a Fiber- Plastic Exper <br /> New Existin Gallons Tanks Concrete Steel glass App. <br /> Tanks Tanks stru ted <br /> Septic Tank or Holding Tank I low E] ❑ 11 11 <br /> lift Pump Tank/Sip hon Chamber El Q ❑ ❑ <br /> VIII. RESPONSIBILITY STATEMENT ILL <br /> I,the undersigned, assume responsibility for installation of the onsite sewage system shown o the attached plans. <br /> Plumber's Name:(Print) Plumber's Signature:(N Sta s) MP/MPRSW No.: Business Phone Number: <br /> c Pk1r/s 3.47.` 4- /.r7 <br /> Plu ber's Address(Street,Gty,State,Zip Code): IF I <br /> 2?1 foo i14W4 3T 111 - 5 8g 3 <br /> IX. COUNTY/ DEPARTMENT USE ONVY <br /> E]Disapproved Sanitary Permit Fee (Indudeiaroundwater Date Issued I ui gent Sign e(No Stam ps) <br /> Approved I�^ •�. <nargelee) <br /> PP ❑Owner Given Initial Jl ' <br /> Adverse Determination <br /> X. ONDITIONS OF APPROVAL/ REASONS FOR DISAPPROVAL: <br /> SKI)6398(R.05194) DISTRIBUTION. Original u>(our,l y,On.ropy To: Svlery&RiniVin,nlm;ioq owner,Pl..,, <br />