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• <br /> DiLwa i SANITARY PERMIT APPLICATION Bureau of Building Water'Systems <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 1/2 x 11 inches in size. �,q 9 7-0 t g <br /> • See reverse side for instructions for completing this application State Sanitary Permit Number <br /> The information you provide may be used by other government agency programs ❑Check if revision to previous application <br /> (Privacy Law,s. 15.04(1)(m)I. -• <br /> State Plan I.D.Number <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION I y7 0$ <br /> Property Owner Name <br /> Property Location <br /> 373"re- � ✓ALatojl A/ ,1/4 Property <br /> 1/4,530 T 9 ,N,R // E(or-W <br /> Property Owner's Mailing Address , Lot Number Block Number <br /> City,State - Zip Code Phone Number Subdivision Name or CSM Number <br /> m'4 '/AA/ kiff 5-3 717 ( ) C-S -r moo <br /> II. TYPE OF BUILDING: (check one) ❑ State Owned ❑Cit Nearest Road <br /> 3 ❑ Village �/ 2.1 sro[� <br /> ❑ Public 41 1 or 2 Family Dwelling-No.of bedrooms ,,Town OF jqp A{t 49, <br /> III. BUILDING USE: (If building type is public,check all that apply) Parcel Tax Nubmber(s) /� <br /> 1 ❑ Apartment/Condo <br /> O — O9r" -J°% Sari a <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 12 ❑ ServiceStation/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) 1.121 New 2. ❑ Replacement 3. ❑ Replacement of 4_ ❑ Reconnection of 5. ❑ Repair of an <br /> System System Tank Only Existing System Existing System <br /> B) ❑ A Sanitary Permit was previously issued. Permit Number Date Issued <br /> V. TYPE OF SYSTEM: (Check only one) RECE� <br /> Non-Pressurized Distribution Pressurized Distribution Experimental "9Ar <br /> 11•❑Seepage Bed 21 ❑Mound 30❑Specify Typ�r 1 6 ' ❑Holding Tank <br /> 121 'Seepage Trench 22❑In-Ground Pressure tape Co ❑Pit Privy <br /> 13❑Seepage Pit y�rrl�th y Envir 43❑Vault Privy <br /> 14['System-In-Fill . nom_ On—entr <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 /> ��O <br /> Required(sq.ft.) Proposed(sq.ft.) (Gals/day/sq. ft.) (Mi7/nth) 98 a- Elevation 9 t> 9b C. V- S �t,4 9,P.c> Feet /any./o/Feet <br /> Capacity Site <br /> VII. INFORMATION <br /> in allon Geloltons anks Manufacturer's Name Concrete Con- Steel g ass Plastic Exper. <br /> New Existing strutted <br /> Tanks Tanks <br /> Septic Tank or Holding Tank /V PP' POD / Cs/i 6S Ede lit ❑ ❑ ❑ ❑ ❑ <br /> Lift Pump Tank/Siphon Chamber tpD) (ova / 1' --,---Eg ❑ ❑ ❑ ❑ ❑ <br /> VIII. RESPONSIBILITY STATEMENT <br /> I,the undersigned,assume responsibility for installation of the onsite sewage system shown on the attached plans. <br /> P`lumber's Name:(Print) PI m.er's Sig �:L] <br /> atYe :( Stw / IMP/MPRSWN0.. Business Phone Number: <br /> 'umber's Address(Stree ,Cit ,S te,Zip Co ): <br /> ,46 p s .g yg d' u,L_0L h U 5 , . 33 <br /> IX. COUNTY/DEPAR ENT USE ON LY <br /> 0 Disapproved Sanitary Permit Fee (Includes Groundwater ate Issue Issuir• ••-nt igna/ ��o Stamps) <br /> A roved ep Surcharge Fee) <br /> pp ❑Owner Given Initial </ 5 �I 4 ,/� <br /> Adverse Determination v�S� ?1 J�t1 ��/C�O�'''�' t" •,` <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br />