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. -- J!R-18-99 FRI 03:09 PM D3DHS NPO FAX NO. 608 242 6256 P. 02
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<br /> ,,� '° '�� Sa fety and Buildings Division
<br /> rr.,■urgr. SANITARY PERMIT APPLICATION Bureau of Building Water Sys
<br /> 701 F.Washington Ave
<br /> i In accord with ILHRF1?05,Wis.Adm Code P O.Box 79698
<br /> , Madison,WI 53707-7969
<br /> ' • Attach complete plains(to the cDunty copy only)for the system,on paper not less 'County
<br /> tit)n 8 1/2 x 11 inches in size. Dane `'ie -C, 2 (.,
<br /> • Se:reverse side for instructions for completing this application State Sanitary Permit Number f
<br /> The infcrmation you provide may be used by other government agency programs nchrv:k ii revision IC)pievluus applux.ii.m
<br /> IPrivac.r Law,s. 15 0A(1)(rn)I.
<br /> State Plan I.D.Number
<br /> I. APPLICATION INFORMATION-- PLEASE PRINT ALL INFORMATION 229109
<br /> Proper •Owner Name Property Location "�
<br /> II it-, R _y T iL.:.,.)-r1 ,r NE 1/4 Ss 1/4,5 2 T 6 ,N, R 7 E g/ryr,•
<br /> Proper; Owner's Mailing Address Lot Number TM Block Number
<br /> 8205 1:,1eve��v: lle-1ki,jO Rood N.A. N.A.
<br /> CiLy,.St.i c 7•1pCcde Phone Number Subdivision Name or C5M Number
<br /> D;cm.i. ern. 5:693 (60(3 ) 345-9150 N.A.
<br /> II. •TY5EOFBUILDING: (check one) D State Owned oat Nearest Road
<br /> —C Public n 1 or 2 Family Dsv-)1 n - No.of bedrooms ' 3 j n Tour OF S Trin1•do11e ri1evenville-Riley
<br /> Y _9 �s�9`I l e, F � �
<br /> I. BALDING USE: (I f building type is public,check all that apply) Parcel Tux Nurr\ber(s)
<br /> 1
<br /> .1 ❑ Apartment/Condor. rG�7-- � -� Cr
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<br /> 2 ❑ Assembly Hall 6 ❑ Medical Facility!Nursing Home 10 ❑ Outdoor Recreational Facility
<br /> 3 ❑ Campground 7 ❑ Merchandise: Sales/Repairs 11 a Restaurant/Bar/Dining
<br /> 4 ❑ Church/School 8 ❑ Mobile Home Park 12 ❑ Service Station/Car Wash
<br /> • 5 ❑ Hotel/Motel 9 ❑ Office/Factory 13 ❑ Other: specify ,
<br /> IV. TYPE OF PERMIT: (Check orly one box on line A. Check box on line B,if applicable)
<br /> A) _ ❑ New 2. Replacement 3. Replacement of 4, ❑ Reconnection of 5, ❑ Repair of an
<br /> System System Tank Only Existing System Existing Syrsten
<br /> 8) ❑ A Sani tary Permit was previously issued. Permit Number__ Date Issued
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<br /> V. TYPE OF SYSTEM: (Check orly one)
<br /> Non pressurized Distribution Pressurized Distribution Experimental Other
<br /> 11 ❑'.eepage Bed 21 ❑Mound 30❑Specify Type 41 Q Holding Tank
<br /> 1 2 0'.eepage Trench 22❑In-Ground Pressure 42❑Pit Privy
<br /> 13[,l',eepage Pit 43❑Vault Privy
<br /> 14❑'.ystertl•In-Fill
<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 /> Required(sit, ft.) Proposed (sq. ft.) (Gals/day/sq.ft.) (Min./inch) Elevation
<br /> X67 N.A. N.A. N.A. M.A. L N.A. Feet N-A- Feet
<br /> . VII. TANK Capacity
<br /> INFORMATION in gallons Total T of Manufacturer's Name Prefab. Site Fiber- plastic [xpe'
<br /> New Existing Gallons Tanks Concrete st acted Steel yla$s App.
<br /> _....- — Tanks anks 0
<br /> septic T ar k t l lolcilr Lsiik r t 0 ❑ ❑ 0 ❑ ❑
<br /> f - 4_-T'r�- .�� ���F� s.?l��l 1(A)i)11 � C:,�,�'�'tr T7'a'� tir- 7.ii .
<br /> I,h Pump Tank/Sipl,nn Climber ❑ ❑ ❑ ❑ El Cl
<br /> ViIi. RFSPONSIBILITY STATEMENT
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<br /> I, ll I.:undersigned, a55ume responsibility for installation of the onsite sewage system shown on the attached plans.
<br /> Plumber r Name'(Pont) Pli,.Ari g"nal4re?,(No Stamps) f ,, MP/M3.R,S•W'No. Business Phone Number:
<br /> `r (�.r^4,' t�?,,rra1e?c," ���;,^, ��:`f r ." � to C`�r f` Fi�.,i{"�C/ 608)437--.3068
<br /> Plumber s Address(Street,City,State,Zip Coe!';).
<br /> ir12,-1J r%,irs !_i Prc.ai- P.L. i.nrih- 1ft. SI577 _
<br /> IX. COUNTY/DEPARTMENT USE ONLY _
<br /> ❑Disapproved Sanitary Permit Fee f".•wdceor:,..ntlwomr Da e Issued !stuff •A.0.1)1 Si nature rnp
<br /> A IOVed i..J Swchargi•irp) `,,
<br /> .pp ❑Owner Given Initid I //
<br /> Adverse Detcrrminl)lion 1rf /1' /`
<br /> X CONDITIONS OF APPROVAL /REASONS FOR DISAPPROVAL:
<br /> k'‘-A-r :; � 5 r Ke-' .(r-, i 1,4_ 7 . 1 i _1/,... C.c 'C... c n, Gz_./,..c)" .-t_..
<br /> `•unbPA(Ii }'✓`i1) DisTRiouhnN OF ooTinal titr i n...,, r... . ..,.......,...... .. - •
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