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Safety Buildings Division <br /> SANITARY PERMIT APPLICATION 201 W.Washington Avenue <br /> `�sconsin In accord with ILHR 83.05,Wis.Adm.Code P O Box 7302 <br /> Department of Commerce Madison,WI 53707-7302 <br /> • Attach complete plans(to the county copy only)for the system,on paper not less Co ty ��02 3 <br /> than 8 vi x 11 inches in size. Lk'RN 43 <br /> • See reverse side for instructions for completing this application SISle S ry�Perit tuber 33 210-5) <br /> Personal information you provide may be used for secondary purposes p Check ifsre`isionn ,moo ev ous application <br /> [Privacy Law,s. 15.04(1)(m)]. State Plan I.D.Number /� <br /> 1. APPLICATION INFORMATION- PLEASE PRINT ALL INF RMATi N 41 <br /> Property,Owner Nam Prop Location <br /> ZIM /a 1/a,5 T N, R 6 E(c <br /> Property Owner'sMailin Address Lot Number <br /> it i.- ST_ G0 <br /> City,State Zip Code MRne`)umber-�q� Subdivision Name or CSM Number <br /> v �� <br /> III. TYPE F B IL I G: (check one) ❑ State Owned 0 City /� Nearest Road Q(� <br /> Village © �Y I �l W !- <br /> El Public 1 or 2 FamilyDwelling-No.of bedrooms Town OF <br /> III. BUILDING USE: (If building type is public,check all that apply) Parcel TaxNumber(s) [, <br /> 1 E] �'� <br /> Apartment/Condo Zo S �2 Doo <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.,KReplacement 3_ ❑ Replacement of 4_ ❑ Reconnection of 5. ❑ Repair of an <br /> System --------System --------- _-_ Tank Only------- _ +�gExisting ystem -__---___ExlstingSystem <br /> B) *A Sanitary Permit was previously issued. Permit Number r_304.7 4 Date Issued 10-;Z4 <br /> V. TYPE OF SYSTEM: (Check only one) <br /> Non-Pressurized Distribution Pressurized Distribution Experimental Other <br /> 11 M Seepage Bed 21 E]Mound 30 E]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 Rate 5.Perc. Rate 6. System Elev. 7. Final Grade <br /> Re Ire (s�`ft.) Proposed sq.ft.) (Gals/day/sq.ft.) (Min./inch) E evation <br /> PIS W4� J^ s• O Feet s Feet <br /> Capacity <br /> Vit INFORMATION in gallons Total #of Manufacturer's Name Prefab. Con- Steel Site fiber- plastic Exper. <br /> New Exist Gallons Tanks concrete structed glass App. <br /> Tanks T nin Ip <br /> Septic Tank or Holding Tank two 000 A ❑ ❑ ❑ ❑ ❑ <br /> Lift Pump Tank/Siphon Chamber I I ❑ ❑ ❑ ❑ ❑ ❑ <br /> VIII. RESPONSIBILITY STATEMENT <br /> I,the undersigned,assume responsibility for installation of the onsite sewage system shown on the attached plans. <br /> Plum er,s Name:(Print) Plumber's Signature: O MES) r:z;z-s <br /> P/MPRSW No.: rliisl <br /> ss Phone Number: <br /> LOA9n 1 PP„�s85f - r6- 415-7 <br /> Plu tier's Address(Street,City, ate,Zip Code): ` '�� � � , S�-493 <br /> 2- �0 w W <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑Disapproved Sanitary Permit Fe (includes ate IssuedIssuin Ag Signa re(No St ps) <br /> 09-roved (e�iSurcharge Fee) <br /> 0 1Adverse Determination <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(R.11/97) DISTRIBUTION: Original to County,One copy To: Safety 8 Buildings Division,Owner,Plumber <br />