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Safety and Buildings vision <br /> r^�iC.:is SANITARY PERMIT APPLICATION Bureau of Building Water Systems <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 8112 x 11 inches in size. :,j <br /> • See reverse side for instructions for completing this application State Sanitary ermit�Mber _ <br /> The information you provide may be used by other government agency programs ❑Check if rCGel�vision(D previous application <br /> [Privacy Law,s. 15.04(1)(m)]. State Plan l.D.Num er <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION <br /> Property Owner Name perty Location <br /> MIKE M09/4/4 1141,S T N, R s E(orQ <br /> Property Owner's Mailing Address Lot Number Block Number <br /> E. <br /> Cit ,State - Zip Code ' (h nee Nu-rube; o <br /> Is5o Ig <br /> II. TYPE F BUILDING: (check one) E] State Owned O Elity Nearest Road <br /> Public 1 or 2 FamilyDwellingE] Village-No.of bedrooms p- <br /> Town of <br /> III. BUILDING USE: (If building type is public,check all that apply) Parcel TaxNumber(s) u��( W <br /> 1 ❑ Apartment/Condo 3SIs17oo 170\ �i y— �° /7 —Q/l 7 <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. 0 Replacement 3. E] Replacement of 4_ ❑ Reconnection of 5. E] Repair of an <br /> ......System System Tank Only Existing System Existing System <br /> 8) ❑ 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%6eepage 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 5. Perc. Rate 6. System Elev. 1 7. Final Grade <br /> Required (sq.ft.) Proposed(sq.ft.) (Gals/day/sq.ft.) (Min./inch) Elevation3a0 n10 -% <br /> Feet 99.3 Feet <br /> city <br /> Ca <br /> VII. TANK n Ballo S Total #Of Prefab Site Fiber- plastic Exper <br /> INFORMATION New Existin Gallons Tanks Manufacturer's Name Concrete con- Steel glass App <br /> Tanks Tanks strutted <br /> Septic Tank or Holding Tank = ': <br /> IrT <br /> Lift Pump Tank/Siphon Chamber Ej 1:1 El El El El <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 Signatue: oStamps) MP/MPRSW No.: Business Phone Number: <br /> crI AKo efs �t 3�� <br /> Plumber's Address(street,city,Sta e,Zip Code): <br /> 2-1-7W H4 36 486%X 1- 5 3 <br /> IX. COUNTY/ DEPARTMENT USE ONLY <br /> ❑Disapproved Sanitary PermJt Fee ('"dudes Groundwater ate ss e , Issuing n Signa re raps) <br /> Approved ❑Owner Given Initial J / 1 5ur<hargeFee) <br /> Adverse Determination [ JU fc <br /> X. CONDITIONS OF APPROVAL/REASONS FOR'DISAPPROVAL: <br /> SHO-6390(H.05N4) DISTRIBUTION: Original w county,One aapy To: Sakty 6 Ruildings Division,Owner,Plumber <br />