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SANITARY PERMIT APPLICATION 201eE.and W shnlgtonAvesion <br /> NVAwonsin In accord with ILHR 83.05,Wis.Adm Code P.O.Box 7969 <br /> Department of Commerce Madison,WI 53707-7969 <br /> I/ <br /> • Attach c_ mplete plans(to the county copy only)for the system,on paper not less County <br /> than 8112 x 11 inches in size. 13 7-T <br /> • See reverse side for instructions for completing this application State Sanitary Permit Nu <br /> m er <br /> rams information you Provide maybe used b other government agency progg``/miD <br /> (Privacy Law,s. 15.04(1)(m)). Check revision to previous application <br /> State Plan I.D.Number <br /> I. APPLICATION INFORMATION- PLEASE PRINT ALL INF RMATI N <br /> Property Owner Nam Property Location <br /> SAVE X1/4 1/4,S cZ T39 ,N, Rrjt� E(or)W <br /> Property Owner's Mailing AcIldress Lot Number Block Number <br /> g 2 n <br /> City,State Zip Code - Phone Number Subdivipion Name or CSM Number /� <br /> eco 6W ( Sr> Do 1 ` 5® 7 <br /> I1. TYPE OF BUILDING: (check one) ❑ State Owned E] Ct rc <br /> arest Road <br /> El Public or 2 FamilyDwelling-No.of bedrooms a vown OFK <br /> 111. BUILDING USE: (If building type is public,check all that apply) Parcel TaxNumber(s) <br /> 1 [:] Apartment/Condo ` 2� �/� "gab <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. [f�Wew 2. ❑ Replacement 3. ❑ Replacement of 4_ ❑ Reconnection of 5. ❑ Repair of an <br /> - System System T <br /> _ _ Tank Only - ____Existing gSystem_ _____________ ---- <br /> Existing System <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 93-Teepage Bed 21 ❑Mound 30❑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 3. Absorp.Area 4. Loading Rate5. Perc. Rate 6. System Elev. 7. Final Grade <br /> Required(sq.ft.) Proposed(sq:ft.) (Gals/day/sq.ft.) (Min./inch) Elevation <br /> O Feet ?f.67— Feet <br /> VII. TANK Capacity <br /> in gallons Total #Of Prefab. Site Fiber- Ex er <br /> INFORMATION New Existin Gallons Tanks Manufacturer's Name Concrete Con- steel glass Plastic App <br /> strutted <br /> Tanks Tanks <br /> Septic Tank or Holding Tank Ud Off} �� I.J 11 n ❑ ❑ <br /> Lift Pump Tank/Siphon Chamber I I ❑ I El ❑ El ❑ ❑ <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: mps) MP/MPRSWNo.: Business Phone Number: <br /> r , E a ad-go -7l 3 7 Seo <br /> Plumber's Address(street,City,State,Zip Code): <br /> 73M, Z o Ak 12 S'fi lL- LIE- <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑Disapproved Sam y Pgrmit Fee (indude,&..rdw.w ate IssuedIssuing A en igna a No s) <br /> pproved ❑Owner Given Initial (/ yUrFnargefee) <br /> Adverse Determination /�q(0 <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(R.11A6) DISTRIBUTION: original to County.One copy To: Safety f Buildings Division,Owner,Plumber <br />