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��11 I , . . , SANITARY PERMIT APPLICATION Safety ofBuilldi9WateriS stems Bureau of Building y In accord with ILHR 83.05,Wis.Adm.Code 201 E.Washington Ave. .r--:-- P.O.Box 7969 Madison,WI 53707-7969 • Attach complete plans(to the county copy only)for the system,on paper not less County than 81/2 x 11 inches in size. DANA q ----°(-1 /Y • See reverse side for instructions for completing this application State Sanitary Permit Number ,PL SSdCO The information you provide may be used by other government agency programs 0 Check it revision to previous application (Privacy Law,s. 15.04(1)(m)). State Plan I.D.Number I. APPLICATION INFORMATION-PLEASE PRINT ALL INFQRMATION 13 95- 137 Property Owner Name Property Location .• GLL3Elf !-fitY�J�/.J 5E1/4 5,,..,j 1/4,S 3.f T ' ,N,R /? (ems Property Owner's Mailing Address Lot Number Block Number Lel I?1 rA 1-S S o.-2I P.o City,State Zip Code Phone Number Subdivision Name or CSM Number IN 2-S--ALt wl S3SS9 (6c? Y, s: 31 q II. TYPE OF BUILDING: (check one) ❑ State Owned o Cit Nearest Road e❑ Public 1....1 or 2 Family Dwelling-No.of bedrooms �;oan OF tAA -OLJA ( VV1tSS U✓r2, III. BUILDING USE: (If building type is public,check all that apply) Parcel Tax Number(s) v 1 ❑ Apartmen .-_, iy-Oe) Z-� ! ��o ' 2___ 2 ❑ Assembly Hall . • -.' al Facility/Nursing Home 10 ❑ Outdoor Recreational Facility 3 (=I Campgro •: 7 ❑ Merchandise: s.LRepairs 11 ❑ Restaurant/Bar/Dining 4 ❑ •- /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. iieplacement 3. ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an System ystem 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 Experiment Other 11 ❑Seepage Bed 21 ❑Mound 30❑SpecifcE'V 41 ❑Holding Tank 12 epage Trench 22 0 In-Ground Pressure 42 0 Pit Privy 13❑Seepage Pit AUG 2 4 1995 43❑Vault Privy 14❑System-In-Fill VI. ABSORPTION SYSTEM INFORMATION: Dane Courtly Envlronmemal 1. Gallons Per Day 2. Absorp.Area 3. Absorp.Area 4. Loading Rate 5.Pe .I Kate 6.6. Stysstem Elev. 7. Final Grade b �o Required(sq.ft.) Proposed(sq.ft.) (Gals/day/sq.ft.) (Min-./i h) 5t.(,‘ ' 46;1 , Elevation , /2.-o c.. (2 o CS 6- 'S-- ^-//.4-- 4r.3 `�9-6 J Feet too ; ZoFeet VII. TANK Capacity in gallons Total #of Prefab. Site Fiber- Ex er. INFORMATION New Existing Gallons Tanks Manufacturer's Name Concrete stCon- Steel glass Plastic App Tanks Tanks Septic 1anks‘r Holding tank /287 OW:49Q Mal f- Z Dr4l vv.A a./+ ,J ❑ ❑ ❑ ❑ ❑ Lift Pump Tanker 7 -770 I 0itt'vhl1•4 ( _ iff ❑ _ ❑ ❑ _ ❑ ❑ VIII. RESPONSIBILITY STATEMENT I,the undersigned,assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber's Name:(Print) Plumbe s i nature: • Stamm riPiterfiffEW No Business Phone Number: DO fJ AIc > P�°s-cdtV-E. _ / . I'ZE - ../ --� 5-%-? 16 c-S--32y.1 Plumber's Address(Street,City,State,Zip Code): 12'i POLL-SIDe-- aQ-■ (Mfs-Rst-4A-C,C G.Ji S-3SS'q IX. COUNTY/DEPARTMENT USE ON LY , (Includes DatBBTT Issued Is -'.en igna J.Stamps) ❑Disapproved Sanitary Permit Fee Surcharge Fee) Approved ❑Owner Given Initial 11 / Adverse Determination c �� >ZSIy -- `* i ■, X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: E-,cISTilUZ., etc_ ,s j2(,1:3a 3'- f ' C-Belitel—A1\ ' Zi ORR AnD Oie—kere AS' -Y % ., SBD-6398 IC.OS/94) DISTRIBUTION'. Original to Cnuray.One copy To: Safety&Ruildings Dina.on,Owner,Plumber t