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- D4MR <br /> Safety and Buildings Division <br /> SANITARY PERMIT APPLICATION Bureau of Building Water Systems <br /> 201 E.Washington Ave <br /> M_ <br /> accord with ILHR 83-05,Wis.Adm.Code P.O.Box 7969 <br /> Madison,WI 53707-7k69 <br /> • Attach complete plans(to the county copy only)for the system,on paper not less count _ /� <br /> than 8112 x 11 inches insize. /,cJe_r/ aIS <br /> • See reverse side for instructions for completing this application State Sanitary Permit Number <br /> �»�4DO <br /> The information you provide maybe used by other government agency programs E]Check it revision to pr sous application <br /> lPrivacyLaw,s. 15.04(1)(m)]. State Plan l.D.Numb r <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION <br /> Property Owner Name Property Location <br /> e 1/4 1/4,S_3y T _3-,9 N, R/6 E(or)O <br /> Property 0 ner's Mailing Address Lot Number Block Number <br /> ?So9 L A ee- <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> II. TYPE F BUILDING: (Check one) ❑ State Owned ity Nearest Road <br /> ❑ Village <br /> El Public. 1 or t Family Dwelling- No.of bedrooms '2 town OF eC,,iJoxo LAe— Ute <br /> III, BUILDING USE: (If buildingtype is public,check all thatapply) Parcel TaxNumber(s) <br /> 1 ❑ Apartment/Condo O ff$ — �?%.;2 5— — a n d <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. LgReplacement 3. ❑ Replacement of 4_ ❑ Reconnection of 5. ❑ Repair of an <br /> System System ___- _______ TankOnly---------------Exi sting Syste <br /> _____ ____ExlstingSystem ___ ___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 ❑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 �y�y�fr�lrrs 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 /> Required (sq. ft.) Proposed(sq.ft.) (Gals/day/sq.ft.) (Min./inch) Elevation <br /> 900 J75" 3�S " IF FeetyObO Feet <br /> Capacity <br /> VII. llos Total #of Prefab. Site Fiber- Plastic Apec <br /> INFORMATION in <br /> g Gallons Tanks Manufacturer's Name Concrete CO"' Steel glass pp <br /> New Existin stA <br /> rutted <br /> Tanks Tanks <br /> Septic Tank or Holding Tank 7S0 1 175-z) ❑ ❑ ❑ ❑ ❑ <br /> Lift Pump Tank/Siphon Chamber S-Cp 1 jSOo ❑ ❑ ❑ ❑ ❑ <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) rim—PIM PRSW No.: Business Phone Number: <br /> Xa1,2 Gt1 ��% <br /> Plumber's Address(Street,City,State,Zip Code): 101, <br /> IX. COUNTY/ DEPARTMENT USE ONLY <br /> E]Disapproved SanitaryPermitFee (indudesGroundwater ate Issue Issum A ntSig�re N to ) <br /> proved ❑Owner Given Initial ec77�� Surcharge tee) <br /> Adverse Determination <br /> X. CONDI <br /> 'TI S F APPROVAL/REASONS FOR DISAP,[P�ROV/AL: <br /> -I-/� Qci r �(�G �cli�lGlt�rS. <br /> SR0.6398(R 05/94) DISTRIBUTION: original to(oura ,One copy To: Safety 8 ,ildinga Div.ion,Owner,Plumber <br />