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/VoraK7 �1��7 <br /> Safety and Buildings Divisi n <br /> vt1�. lOri SANITARY PERMIT APPLICATION Bureau of Building Water System! <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 8 112 x 11 inches in size. ar <br /> • See reverse side for instructions for completing this application state Sanitary )rmit ru mbe� <br /> The information you provide may be used by other government agency programs ❑Gheck I rev In to previous application <br /> (Privacy Law,s. 15.04(1)(m)]. State Plan I.D.Number /� <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION N <br /> PropeOwner Name Property Location <br /> rt l 1,/ <br /> D$ 1/4 SW 1/4,S .33 T40 ,N, R $ Elor <br /> Property Owner's M Ling Address Lot Number r <br /> 7 t1wu SZ I IZO AtgC5 <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> ocH E N S of 1(501)299-5A27 p <br /> . TYPE OF BUILDING: (check one) ❑ State Ownedity Nearest Road <br /> Public 1 or 2 FamilyDwelling-No.of bedrooms Z To age <br /> OF W HAPSAL 11d EED Town <br /> III. BUILDING USE: (If building type is public,check all that apply) Parcel Tax Number(s) <br /> 1 E] Apartment/Condo j% y,3 <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 <br /> 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.-gReplacement 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 /> 1 i-M5eegagQ4" 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 /> b <br /> Required <br /> 03-7-5- .375 <br /> ft.) Pr 375(sq.ft.) (Gal/ay/sq.ft.) (Min./in(h) �Jr 7 Elevation <br /> r`_ Feet 9S.2- Feet <br /> VII. TANK Capacity <br /> INFORMATION in gallons Total #of 's Name Prefab. Site Fiber- Exper <br /> New Existin Manufacturer <br /> Gallons Tanks Concrete co" Steel glass Plastic App <br /> strutted <br /> Tea �,nks Tanks <br /> Septic Tank or Holding Tank 900 Soo I <br /> Lift Pump Tank/Siphon Chamber El ❑ I EJ El El El <br /> Vlll. 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 amps) MP/MPRSW No.: Business Phone Number: <br /> 1 clfRRv p� n15 34Z� (5- <br /> Plumber's Address(Street,City,State,Zip Code): <br /> 1_'7-7(P6 1411ril V 361 JI✓$ST t,J 1 . �4g9� <br /> IX. COUNTY/ DEPARTMENT USE ONLY <br /> �p{�!rl�t^,r_^ ❑Disapproved Sanitary Permit Fee (Includes Groundwater ate ssue Issuin Is tur amps) <br /> !7 roved �Sur<harge Fee) <br /> 77VVV P E]Owner Given Initial S�� (!/U <br /> Adverse Determination l <br /> X. CONDITIONS OF APPROVAL/REASONS FORDISAPPROVAL: <br /> SRD-6398(R.05/94) DISTRIBUTION: Original to county.One copy To: Safety&Buildings Division,Owner,Plumber <br />