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�uWF;;ti Safety and Buildings Division <br /> �.� �; SANITARY PERMIT APPLICATION Bureau of Building Water Systems <br /> E <br /> 201 Washington Ave- <br /> • In accord with ILHR 83.05,Wiz.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 O <br /> than 81/2 x 11 inches in size. <br /> • See reverse side for instructions for completing this application State Sanitary Permit Number <br /> . 60/�a2,;?,The information you provide may be used by other government agency programs L]Check it revision to previous application <br /> (Privacy Law,s. 15.04(1)(m)I. State Plan I .Number n'N <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION /(��FJi <br /> Property Owner Name // Property Location e,/ <br /> O/7,j .5 (J t/4 S J1 A,S a T,35F1 ,N, R 0� E (or W <br /> Property Ownerf Mailing Address Lot Number Block Number <br /> as'a 6P 0 S 3 — <br /> iCity,State Zip Code Phone Number Subdivision Name or CSM Number <br /> �1 e t— Ar_4727 y8'9.5' I( )A-9/S0 <br /> ll. TYPE OF BUILDING: (check one) ❑ State Owned ❑ City Nearest Road <br /> ❑ Village <br /> Public 1 or 2 Family Dwelling- No. of bedrooms 2 aTown OF/01e <br /> III. BUILDING USE: (If building type is public,check all that apply) Parcel Tax Number(s) <br /> 1 ❑ Apartment/Condo V OR 5_00 <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 J4 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 /> "70 Required (sq. ft.) Proposed(sq.ft.) (Gals/day/sq.ft.) (Min./inch) Elevation <br /> Q �O C� e..2 Feet 6 Feet <br /> VII. TANK Capacity <br /> in Total #Of Prefab. Site Fiber- . <br /> INFORMATION gallons Gallons Tanks Manufacturer's Name Concrete Con- steel glass Plastic Exper <br /> New Existin strutted <br /> App <br /> Tanks Tanks <br /> Septic Tank or Holding Tank O ee 4,,74,,7GICFp( <br /> ❑ ❑ ❑ 1 ❑ ❑ <br /> Lift Pump Tank/Siphon Chamber ❑ ❑ ❑ ❑ ❑ ❑ <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 Signature:(No Stamps) MP/MPRSW No.: Business Phone Number: <br /> Plumber' Address(Street,City,State,Zip`iode): <br /> , o e 40—, <br /> IX. COUNTY/ DEPARTMENT USE ONLY <br /> ❑Disapproved Sanitary Permit Fee (indudesGroundwater IR <br /> Issuing Age t Signat ( Stamps) <br /> roved )50_1 h1_ ge fee) <br /> pp ❑Owner Given Initial `/ <br /> Adverse Determination <br /> X. CONDITIONS OF APPROVAL/ REASONS FORDISAPPROVAL: <br /> 9.*71 herr` "��• <br /> W)6398(R.OS/94) MIRIRUTION: original to Cmmty,One urPy To: Safety&Ruiidings Dm ion,Owner,Plumbx <br />