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r A C1 Safety and Buildings Division '�/ `:. • SA A .ICMIOI ,p, : g r j ►'�q • Bureau of Building Water S ster 6 �. -' • 201 E.Washington Ave. In accord with ILHR 83.05,Wis�Ad.Code-' P.O.Box 7969 �sn d Madison,WI 53707-7969 ach com�S� • Tans to the county copy one)'for the system,on' ip .r nojJ ss Ounty ?"---D an 8 1/2 x 1 f'19. in size. ^ " �r r q(c.-G 'S ne Cour�ty Environmental3 O State Sanitary Permit Number See reverse side f`fr,ir s'Iructions for c rilpr tin co �3 r o/- �lec�t�i ' Sr 0 low I 3 e information you provide may be used by other government agency programs Co ❑Check if revision to previous application Privacy Law,s. 15.04(1)(m)J. State P n I. umber I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION Ql( Pro y r)er NaK Property Location 1`, S 0Rivp l 16- .! ..4 4 /s,Aez(i[ ) Nei/4 lied 1/4,S i:92 7T 7 ,N, R 7E(or) Pro ert Owner s Matlt ddress p Lot Number Block Number 37tsa rty,State Zode Phone Numbe Subdivision Name t r CSM Numb•r f b S S {?La l'ns SAS-� (,k( ) !"�f sp? d s - II. TY E OF BUILDING: (check one) ❑ State Owned City Nearest oad ,,11,06-T'Village p� Public ❑ 1 or 2 Family Dwelling No.of bedrooms own OF C�EJ ss L s !II. UILDING USE: (If building type is public,check all that apply) arcel Tax Number(s) 1 ❑ Apartment/Condo /41 -6767-02 Za' aY47-(,,_ 2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility 3 ❑ Campground 7 ❑ Merchandise: Sales/Repairs 11�Restaurant/Bar/Dining 4 ❑ Church/School 8 ❑ Mobile Home Park 12 ❑ Service Station/Car Wash 5 ❑ Hotel/Motel 9 ❑ Office/Factory 13 ❑ Other: specify IV. TYPE OF PERMIT: (Check only one box on line A. Check box on line B, if applicable) A) 1."New 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an ystem System Tank Only Existing System Existing System B) ❑ A Sanitary Permit was previously issued. Permit Number Date Issued V. TYPE OF SYSTEM: (Check only one) Non-Pressurized Distribution Pressurized Distribution Experimental Other 11 ['Seepage Bed 211ACMound 30❑Specify Type 41 ❑Holding Tank 12❑Seepage Trench 2 ❑ In-Ground Pressure 42❑Pit Privy 13❑Seepage Pit 43❑Vault Privy 14❑System-In-Fill VI. ABSORPTION SYSTEM INFORMATION: 1. Gallons Per Day 2. Absorp.Area 3. Absorp.Area 4. Loading Rate 5. Perc. Rate 6. System Elev. 7. Final Grade `fin Required (s ft.) Proposed/(sq.ft.) (Gals/day/sq. ft.) (Min./inch) /.\ ,-}- Elevation G O 4253-7 07 5—�PU 1 ' ! / i V Feet /Q/,J)eet VII. TANK Capacity in gallons Total #of Prefab Site Fiber- plastic Exper INFORMATION Gallons Tanks Manufacturer's Name Concrete Con- Steel glass App. New Existing strutted Tanks Tanks Septic Tank or ThTietrng T3Tik S Spa' I C_Jr_6?If- ❑ ❑ ❑ ❑ ❑ lift Pump Tank/S o-,Cha+>nber -S CZ) , / 1( ❑ ❑ ❑ ❑ ❑ VIII. RESPONSIBILITY STATEMENT I,the undersigned,assume respo• ' 'ty for inst. . ion • the onsite sewage system shown on the attached plans. Plumber's Name:(Print) •er' Ig 'e S .mp ) t /MPRSW No : Business Phone Number: :_' 'ALIA •off .,1, At - --s7s 6Q8 - Fc3k- 1°3 PI .er'- ••.res treet,Cut ' ate, p C07,3121111".- .• 4# — ---- . /' -. A—/JAZ" -----' �? 7 IX. COUNTY/ 1 EPARTM ' NT USE ON LY ❑Disapproved Sanitary Permit Fee (Includes Groundwater Date Issue Issuin• .,ge Signature(No Stamps) Approved ❑Owner Given Initial ((JJ �� Surcharge Fee) , � Adverse Determination �%Z ,' AO—/_y� X. CONDITIONS OF APPROVAL/ REASONS FOR DISAPPROVAL: SIll1-6398(ft 05'94) OI`.T 811111 TI ON Original!4 CIIIIIII y.Orre(I,Py To 5,,fety 8.R„ild,.os nivr.lor,.()w„er,Plumber w