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/,�� <br /> .ur / rZi Su ety and Buildings Water <br /> Sy ,y <br /> SANITARY PERMIT APPLICATION Bureau a Building Water Systeme <br /> 201 E.Washington Ave. <br /> In accord with ILHR 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. "B1.4rneltA <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 []Check if revision to previous application <br /> (Privacy Law,s. 15.04(1)(m)). State Plan I.D.Number <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION <br /> Property Owner Name Property Location <br /> 2 L6SEL 01petA 1/4 1/4,S may! T O ,N, R /� W <br /> Property Owner's Mailing.AddressLot umber Block Number <br /> 1130 bem �Ptlj 44S <br /> City,State Zip Code Phone Number Su ivision ame or CSM Number <br /> rtev 5 Y ( <br /> 11. TYPE OF BUILDING: (check one) ❑ State Owned ❑ City Nearest Road <br /> Vil <br /> Public 1 or 2 FamilyDwelling- No.of bedrooms � ❑ owlange <br /> OF 6e0lli �beKTS <br /> III. BUILDING USE: (If building type is public,check all that apply) Parcel TaxNumber(s) <br /> 1 ❑ Apartment/Condo I U2-9 0.2 V, l3O0 <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.�eplacerrent 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 /> 1156eepage 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 /> Requir d(sq. ft.) Proposed(sq.ft.) (Gals/day/sq. ft.) (Min./inch) Elevation <br /> ,ja.4 IF-3.3 Feet 9.673 Feet <br /> Capacity VII. TANK in Cans Total #of Prefab. Site <br /> galloFiber- Plastic Exper. <br /> INFORMATION Gallons Tanks Manufacturer's Name Concrete Con- Steel glass App. <br /> New Existin strutted <br /> Tanksl Tanks <br /> Septic Tank ori p 75-c ❑ El El ❑ <br /> Lift Pump Tank/S OD ❑ ❑ El El ❑ <br /> VIII. RESPONSIBILITY STATEMENT <br /> I, the undersigne sWf a rwessponsi ity for installa n of the onsite sewage system shown tans. <br /> Plumber's U�)8t EXCAVATIO <br /> I mber's gnaturep oStamps) MP/MPRSW No: G usln s r l>re .r S�� <br /> �"lill"a Caiift Line Rd. o� O 7/ 5/ � <br /> Plumber's Address b& ~j)Code): Jul �. ) ' <br /> 718)i35-7482 9Inh <br /> IX. COUNTY/ DEPARTMENT USE ONLY <br /> ❑Disapproved Sanitary Permit Fee (In"udes6roufee)ndwater ate Issue Issuing A e a p <br /> Surcharge <br /> pproved ❑Owner Given Initial <br /> Adverse Determination (�`—Gpoop k <br /> X. CONDIT NNS OF APPROVAL/REASONS F SAPPROVAL: <br /> ,�///�S C- <br /> SND-6398(R.05M) DI.T'RIRUTION: Original to County.One copy ToSafety&Ruildingn Divi ion,Owner,Plumtkr <br />