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SANITARY PERMIT APPLICATION COUNTY In accord with ILHR 83.05 Wis.Adm. de Can e '9 if-6373 STATE SANITARY PERMIT# —Attach complete plans(to the county copy only)for the system,on pr not less than �)(2 a6)Z 8%x'11 inches in size. JUL 1 2 1994 ❑Check If revision to previous application -See reverse side for instructions for completing this application. STATE PLAN I.D.NUMBER L APPLICANT INFORMATION—PLEASE PRINT ALL INFOFIllte♦> ounty Environmental PROPERTY OWNER 11110MIATYNPRISWIerit 5COtt RoMt f p A ,, y4 IJEy4,S 10 T8 ,N,R (0 E PROPERTY OWNER'S MAILING AINIRESS LOT# BLOCK# 3'7(10 Par K ,noll D . 65" I CITY,STATE, ZIP CODE PHONE NUMBER SUBDIVISION NAME Mia /So/1 WI 5-3701, (lsog )-b37•2o4 SUr\bve5t II. TYPE OF BUILDING: (Check one) ❑State Owned CITY NEAREST ROAD jQ�y �p Bo l eat k KrveII 0r- 0 Public FI 1 or 2 Fam.Dwelling-#of bedrooms ARCELY�4X NUMBERS$ III. BUILDING USE: (If building type is public,check all that apply) 07 Oe$i O- so, -2.5 os --7 1 ❑ ApVCondo 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 in line A. Check line B if applicable) A) 1. ❑ New 2. eplacement 3. ❑Replacement of 4.❑ Reconnection of 5.❑ Repair of an System System Tank Only Existing System Existing System B) ❑ A Sanitary Permit was previously issued. Permit# Date Issued V. TYPE OF SYSTEM: (Check only one) Non-Pressurized Distribution Pressurized Distribution Experimental Other 11 i d Seepage Bed 21 ❑ Mound 30 CI Specify Type 41 ❑ Holding Tank 12 ❑ Seepage Trench 22 ❑ In-Ground 42 ❑ Pit Privy---......L. 13 0 Seepage Pit Pressure 43 0 Vault Privy 14 ❑ System-In-Fill 2-2._ 7`.... �b /e?2_ t 4 .11<e),, 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 REQUE IR (sq.ft.) PROPOSED(sq.ft.) (Gals/day/sq.ft.) (Min./inch) ELEVATION '750 `8 5 1R92_ b.44 N A 9%3 Feet 98-G Feet VII. TANK CAPACITY Site in gallons Total #of Mfacturer's Name Prefab. Fiber- Plastic Exper. Manufacturer's Con- Steel INFORMATION New Existing Gallons Tanks Concrete strutted glass App. Tanks Tanks Se'tic Tank• ;•.e.lb •• 2C5C G _ IA ad : y • d r: — — Lift Pump Tank/Slphon Chamber • _ CI VIII. RESPONSIBILITY STATEMENT I,the undersigned,assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber's Name(Print): Plumber's Signature:(No Stamps) 'MP/MPRSW No.: Business Phone Number: 63wcn serves .., 1. • ...- I 360 I ( 6t')857-szs7 Plumber's Address(Street,City,State,Zip Code): (f0412 R a'-)inan Rd. Mad;son t Wr s37o5L IX. COUNTY/DEPARTMENT USE ONLY 9 Disapproved Sanitary Permit Fee(Incluew Groundwater wini Issuing A ntt gcnature( ps) XApproved o Owner Given Initial �450� I'arpe Fes) Adverse Determination X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: ft NmI( M ci -r "Ai, ,4,/2) 2'4 r- E?((cr,wr- -ea rx TANK 12, Vg/py Si eel s-,CK C7-6{A Co' /7?-0,.1( 160 8A E• i t3-i2 0R # f410E SG N -C-rf4)e 4 vAit,4 rc4 t.s * Ul 1 f crizi,x sxtsrews Ott l n/F t ego I s 7o B conisi<oecer FoR a sib -w.Q.• V4iu leev or nudb-Maury r 50784cdic- i Ltorvel srz.€ o se'rc qz tsskcsT, SBD-6398(R.08/93) DISTRIBUTION: Original to County,One Copy To:Safety a Buildings Division,Owner,Plumber