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„-�W a^ Safety and Buildings Division roO■�r■rt SANITARY PERMIT APPLICATION Bureau of Building Water Systen 201 E.Washington Ave. In accord with ILHR 83.05,Wis.Adm.Code P.O.Box 7969 Madison,WI 53707-7969 • Attach complete plans(to the county copy only)for the system,on paper not less County Q than 8 1/2 x 11 inches in size. Do s . - ) -049 • See reverse side for instructions for completing this application State Sanitary Permit Number � The information you provide may be used by other government agehcy programs ['Check it revision to previous application (Privacy Law,s. 15.04(1)(m)l. State Plan I.D.Number I. APPLICATION INFORMATION- PLEASE PRI'f T ALL INFORMATION I 9-7 0-71 Property Owner Name Propert Location 5 0 e 4 6O n r10. rorg ten o - 1/4 5 1/4,S 3 I T ' 1 ,N,R 1! E(er?-VWF Property Owner's Mailing Address Lot Nu Aber Block Number 1%to E. cear, a. 'v---- Cit ,State Zip Code Phone Number Subdivision Name or CSM Number City, Stai k)1 537)(0 (look- aaa-12512 • Qjrat t ra.r'm 5tittr II. TYPE OF BUILDING: (check one) ❑ State Ov rned • ID City Neeares Road ❑ Family 9 _ ❑ To age ( dve_ J 1991 Gk0W Public 1 or 2 Famil Dwelling-.No.of bedrgoms Town OF ` 1 led III. BUILDING USE: (If building type is public,check all thatapply) Parcel Tax Number(s) 1 ❑ Apartment/Condo O I—011 l — 3 t 3- 8541-3 2 ❑ Assembly Hall 6 ❑ Medical Facilit /Nursing Home 10 ❑ Outdoor Recreational Facility 3 ❑ Campground 7 ❑ Merchandise: ales/Repairs 11 ❑ Restaurant/Bar/Dining 4 ❑ Church/School 8 ❑ Mobile Home ,ark 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 System System :Tank Only Existing System Existing System B) ❑ A Sanitary Permit was previously issued. Kermit Number Date Issued V. TYPE OF SYSTEM: (Check only one) ' `' Non-Pressurized Distribution Pressurized Di tribution Experimenta�ECEtVEDOther 11 ❑Seepage Bed 21 ❑Mound 30❑Specify,Ty e r-5 ;41 ❑Holding Tank 12 ix Seepage Trench 22❑In-Grow d Pressure f' �' `' 42❑Pit Privy 13❑Seepage Pit 431:1 Vault Privy 14❑System-In-Fill me County Environmeh I VI. ABSORPTION SYSTEM INFORMATION: yculllr Dcgar�m�^' 1.Gallons Per Day 2. Absorp.Area 3. Absorp.Area 4. Loading Rate 5.Perc. Rate 6. System Elev. 7. Final:Grade t f Required(sq.ft.) Proposed(sq.ft.) (Gals/day/sq.ft.) (Min./inch) 9j.p Elevation 450 .903 75b Oda iJ A 91"S Feet ''q(c5' ("Feet Capacity VII. TANK • in gallons Total of Prefab. Site Fiber- plastic Exper. INFORMATION Gallons Tanks Manufacturer s Name Concrete con- Steel lass App. New Existing strutted g Tanks Tanks Septic Tank oTMetulnTg'I Ib..b ` ICCSO ta``MQC ❑ ❑ ❑ ❑ ❑ Lift Pump Tank/SiahnaChamber 4,015 -- 463 iI 1 `rnOS N kJ , ❑ El 0 ❑ _ ❑ VIII. RESPONSIBILITY STATEMENT ` I,the undersigned,assume responsibility for install Rion of the onsite sewage system shown on the attached plans. Plumber's Name:(Print) umber's Signature:(No Stamps) 1,A /MPRSW No.: usiness Phone Number: Sieve_. Tesmer- -03(do tAote)g31 - 6aci l Plumbp's0Add,r r�s(Street,Ci y State,Zip Code):^ ,, t S�1, ` ; 63104 IX. COUNTY/DEPARTMENT USE ONLY 1Y11,u��.IL w El Sanitary Permit Fee (Includes Groundwater Dat Issued Iss . •.- t Si.natur 1 4,a .tamps) �} Surcharge(ee) Approved ❑Owner Given Initial /'� !�� ``� ,'` _ Adverse Determination c Sb _ �' C ,:5."• X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: SBD-6398(R.05/94) DISTRIBUTION Original ru Counly.One cone To Safety P.Buildings Div,,on.Owner.Plumber