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t45A 7 (,rh)jz <br /> Safety and Buildings Division <br /> SANITARY PERMIT APPLICATION Bureau of Building Water System <br /> ri��Lf1R 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 --rr c',c��`� <br /> than 8 112 x 11 inches in size. RNI� 6 5 x " <br /> • See reverse side for instructions for completing this application State Sanitary r'J b r <br /> The information you provide may be used by other government agency programs ❑Check if revision to previous application <br /> (Privacy Law,s- 1 5.04(1)(m)1- State Plan I.D. mber <br /> 1. APPLICATION INFORMATION - PLEASE PRINT ALL INF ORMATION7' � 6`�"� <br /> Propert Owner Name Property Location <br /> v4 1/4,S 5 T N, R1E(o W <br /> PropertyOwner's Mailing Address Lot Number, 81erk-4lmnber <br /> 332'7 Curs I V. �. <br /> City,State Zip Code Ph ne Number Subdivi on Name or CSM Number <br /> WI O ( ) <br /> II. TYPE OF B LDING: (check one) ❑ State Owned• O City jN6eaj7oad <br /> ❑ Village nn� ,'tt� <br /> ❑ Public 1 or 2 Famil Dwelling-No.of bedrooms Town OF 11 fW �_ <br /> ill. BUILDING USE: (If building type is public,check all that apply) Parcel TaxNumber(s) <br /> O20 ' 335 01 400 <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. Q Repair of an <br /> System System Tank Only _______ Existing System__ ___ExistfngSystem <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 3C ❑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 13. Absorp.Area 4. Loading Rate S. Perc. Rate 6. System Elev. 7. Final Grade <br /> Re ulred (sq.ft.) Proposed(sq.ft.) (Gals/day/sq.ft.) (Min./inch) p Elevation <br /> S (p 1•Z r� 99•S Feet�.*M Feet <br /> Capacity VII. TANK in Ca Ballo s Total #of Prefab. Site Fiber- plastic Exper. <br /> INFORMATION Gallons Tanks Manufacturer's Name Concrete Con- Steel glass App. <br /> New Existing strutted <br /> Tanks Tanks <br /> Septic Tank or Holding Tank WCP0 <br /> Lift Pump Tank/Siphon Chamber —� Ej <br /> VIII. RESPONSIBILITY S ATEMENT <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: o amps) MP/MPRSW No.: Business Phone Number: <br /> Pumber'sAddress treet,City 1 tate,Zip Code): <br /> 2-'7760 HwS5 .l89.�; <br /> IX. COUNTY/ DEPARTMENT USE ONLY <br /> ❑Disapproved Sant ar Permit Fe (m des Groundwater ate sSue Issuing Agent gn ur o amps) <br /> harge fee) <br /> roved ❑Owner Given Initial <br /> Adverse Determination <br /> X. CONDITIONS OF APPROVAL/REASONS FORDISAPPROVAL: <br /> SHE)6398(N.05/94) DISTRIBUTION: Original to One a py To. Safety&Ruildi ngs rl mvlOn,Owner.Plumber <br />