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Safety and <br /> in SANITARY PERMIT APPLICATION 201 W.Washington Avenue <br /> '44 no <br /> In accord with ILHR 83.05,Wis.Adm.Code P O Box 7302 <br /> Department of Don+rnerce Madison,WI 53707-7302 <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. U� RILqro�0 <br /> • See reverse side for instructions for completing this application State SanitaryPermit Number <br /> tQ� <br /> Personal information you provide may be used for secondary purposes ❑Check it revion to previous application fwP <br /> [Privacy Law,s. 15.04(1)(m)]. State Plan I.D.Number <br /> I. APPLICATION INFORMATION- PLEASE PRINT ALL INF RMATI N I ,;` '5-10 <br /> Propert Owner Name Property Lgcation <br /> ZL CAMP Mj 1/4 VI 1/4,S 33 T ,N, R Iia, E(or)W <br /> Property Owner's Mailing Address Lot Number Block Number <br /> X517 1iNn1 W} R&D . <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> ST.L ickkis 2 jj - _S5 to 10 ISAA- 1 <br /> II. TYPE OF Bt IL I : (check one) ❑ State Owned 0 City Nearest Road <br /> o Village <br /> Public El 1 or 2 Family Dwelling-No.of bedrooms Town OF V .7 <br /> Ill. BUILDING USE: (Ifbuildingtypeispublic,check all that apply) Parcel Tax Number(s) <br /> VItJ1t�G AALt_/EWIROOKM4 t-rottS�,Au� k]A51t��s �O-2 333 -05 7� <br /> 1 ❑ Apartment/Condo CRMP <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 ❑ Service Station/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. ❑ New 2.y Replacement 3, ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an <br /> ___System ______System T <br /> __ _____ Tank Only____________ m__ Existing System ____ __ Existing <br /> B) ❑ A Sanitary Permit was previously issued. Permit Number Date Issued <br /> V. TYPE OF SYSTEM: (Check only one) <br /> Non-Pressurized Distribution Pressurized Distribution Experimental Other <br /> 11 {Seepage Bed 21 []Mound 30 C]Specify Type 41 ❑Holding Tank <br /> 12 Seepage Trench 22❑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 13. 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) E evation <br /> 23 940 51ZI S (v� 05(c . 35 Q3. (o Feet �(o. 1 Feet <br /> TANK Capact <br /> VII. INFORMATION in allo s alto #of Manufacturer's Name Prefab. Con steel Fiber- plastic Exper_ <br /> New Existin Gallons Tanks Concrete strutted glass App- <br /> New <br /> nks Tanks <br /> Septic Tank or Holding Tank 0 Ol "—' 30 012.: 2 ❑ ❑ ❑ ❑ ❑ <br /> Lift Pump Tank/Siphon Chamber 6(009 !;409 1 ❑ ❑ ❑ ❑ ❑ <br /> VIII. RESPONSIBILITY STATEMENT <br /> I,the undersigned,assume responsibility for installation of the onsite sewage system shown on the attached plans. <br /> Plumber's Name:(Print) Plumber's Signature:74Z <br /> MP/MPRSW No.: Business Phone Number: <br /> �cEf�tRa PKl i5 <r��..a Z25�S7 'I S- %6- 415 <br /> P umber's Address(Street, ity,State,Zip Code): <br /> Z a 5 IME .►(_ 3 <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑Disapproved Sanitary Permit Fee (Includes Groundwater ate ssue Issuing Agen i at e o p <br /> roved <br /> ED <br /> Given Initial iJ �ur<bargeFee) / p <br /> Adverse Determination l �V'aV 1 l <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(R.11/97) DISTRIBUTION: Original to County.One copy To: Safety&Buildings Division,Owner.Plumber <br />