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JU1-20-99 TUE 12:45 PM DJDHS NPO FAX NO. 608 242 6256 P. 02
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<br /> irri 9 a •'I Safety and Buildings Division
<br /> =i i SAN IT O* PERMIT APPLICATION Bureau of Building Water Syste
<br /> 201 E.Washington Ave.
<br /> 1 ,'''' r�`����kcord with ILWR 83.05,Wis_Adm.Code Madison,7969 WI 53707 7969
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<br /> • Att,ich complete plans(19 r t\Pcopy only)for the system,on paper not less . County Q
<br /> that 81/Z x 11 inch ;iYee Dane 15 -0
<br /> • Set'reverse side for instructions for completing this application State Sanitary Permit Number
<br /> The info-nation you provide may be.used by other government agency programs ❑Check ii revision ro previous application
<br /> IPrivaCy-3w,s. 15.04(1)(m)]. State Plan I.D.Number
<br /> L APPLICATION INFORMATION-PLEASE PRINT ALL INFORMATION •_ 229109
<br /> • owner Name Property Location
<br /> The Riley Tav,,rn N1 1/4 SE 114,5 2 T 6 ,N,R 7 Eyanyy
<br /> Property )wner's Mailing Address Lot Number Block Number
<br /> 8205 Klevenvi.Lle--Rile Road N.A. N.A.
<br /> City,5ta1 Zip Co(e Phone Number Subdivision Name or CSM Number
<br /> Verona WI. 53.i93 (608 ) 345--9150 N.A. _ _
<br /> It TV E OF BUILDING: (check ole) ❑ State Owned 3 0 vIla a [Nearest goad
<br /> El Public p 1 or 2 Family Dwelling-No.of bedrooms _hJ7/ Town OF Springdale Klevenville-Riley
<br /> III. BUILDING USE: (If building type is public,check all that apply) Parcel Tax Number(s)
<br /> 1 ❑ Apartment/Condo 2 C)&3 7- 0.1 `I~ O2Lf�- /
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<br /> 2 0 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 ❑ I:hurch/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 on y one box on line A. Check box on line B,if applicable)
<br /> A) 1. ❑ New 2. K.Repla.:ement 3, Replacement of 4, ❑ Reconnection of 5. ❑ Repair of an
<br /> System Systeri -Tank Only Existing System Existing System
<br /> 8) ❑ A Sanitary Permit was p-eviously issued. Permit Number Date Issued
<br /> V. TYPE OF SYSTEM: (Check on y one)
<br /> Non-P•essurized Distribution Pressurized Distribution Experimental Other
<br /> 11 ❑Seepage Bed 21 ❑Mound 30 0 Specify Type 41 131 Holding Tank
<br /> 12❑ eepage Trench 22 I]In-Ground Pressure 42❑Pit Privy
<br /> 13❑Seepage Pit • 43❑Vault Privy
<br /> 14❑System-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(sq.ft.) Proposed(sq.ft.) (Gals/day/sq.ft.) (Min./inch) Elevation
<br /> 667 N.A. N.A. N.A. N.A. N.A. Feet N.A. Feet
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<br /> VII. T ■NK Capacity
<br /> in gallons Total II of Prefab. Site Fiber• plastic Expe
<br /> INFORMATION g Gallons Tanks Manufacturer's Name concrete Con- Steel glass App
<br /> New E;(isting structed
<br /> Tank -'anks _
<br /> Septic Tar k . iaol ,. - , 7500 2500 10000 2 Crest Precast Inc D-{1 , ❑ ❑ ❑ ❑ ❑
<br /> lift Pump Tank/Siphon Chamber 0 E El 0 ❑ ❑
<br /> VIII. RIESPONSIBILITY STATEMIENT
<br /> I,the undersigned,assume responsibility for installation of the onsite sewage system shown on the attached plans.
<br /> Plumber'.Name: nt) PI ,), na '�� No Stamps) MP o.: Business Phone Number;
<br /> #11.6i ae ( C pt ke l�_ ' 1 - �/ so S j (608)437-3068
<br /> Plumber'. Address(Street,City,State,Zip Code):
<br /> 102 W. Main Street )(t. horeb, WI. 53572 ,
<br /> IX. C()_LINTY I DEPARTMENT U SE
<br /> ❑Disapproved _ Sanitary P rmrt Fee t'no�descro.naware� c 0 Issue. Issui - en Si(nature
<br /> proved surchagcrcc) /,
<br /> Y.6,p
<br /> { ❑Awnes Determination j /�
<br /> Adverse Determination ��_
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<br /> X.-CO VDITIONS OF APPROVAL I APPROVAL FOR DISAPPROVAL:
<br /> , kL:54-v1-.5 TC-4-4.ks o'"1-1.v 1.-c (00---cr-- ,/ . cCa-4,-,-4, ! '2^-
<br /> Sun r,fen(I WO) OISrRIR1111nN. itrinin,il in rm,N. nn.r„„:1n C..,.a n,,,u,,,,,,11,—.
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