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afety and BilBdmgs Division <br /> SANITARY PERMIT APPLICATION 201 W.Washington Avenue <br /> 1V 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 County <br /> than 8 112 x 11 inches in size. T <br /> • See reverse side for instructions for completing this application StAe Sanitary Permit Number <br /> Personal information you provide may be used for secondary purposes 13 V6_6 <br /> ❑Check if revision to previous application <br /> IPrivacy Law,s. 15.04(1)(m)]. State Plan I.D.Number <br /> I. APPLICATION INFORMATION- PLEASE PRINT ALL INF RMATION <br /> Property Owner Name- Property Location <br /> tJ 3014145dtJ 1/4 1/4,S T N,R �(DE(or)W <br /> Propertywner's Mallin Address Lot Number <br /> 2 F—Am AJ. S <br /> City,State Zip Code P neNumber Subdivision Name or CSM Number <br /> w . 55 ( 1) 0 Z7 <br /> 11. P F B BUILDING: (check one) ❑ State Owned 'ty Nearest Road <br /> ❑ Village nQ 90 <br /> Public 1 or 2 FamilyDwelling-No.of bedrooms own of rt IJ <br /> III. BUILDING USE: (If building type is public,check all that apply) Parcel TaxNumber(s) <br /> 1 ❑ Apartment/Condo ©ZD 4-Sz7 OS <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.Weplacement 3_ E] Replacement of 4. E] Reconnection of 5. C] Repair of an <br /> ____System ________System_____________ Tank Only______________ Existing System ________ 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 /> A11 E] E] E]Seepage Bed 21 Mound 30 Specify Type 41 Holding Tank <br /> Seepage Trench 22❑In-Ground Pressure 42❑Pit Privy <br /> 13❑Seepage Pit 43❑Vault Privy <br /> 14❑System-I n-Fi l l <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/�y/sq.ft.) (Min./inch) nn Elevation <br /> _500 1 (obo �—� v61 - I Feet Feet <br /> TANK Capaclt <br /> VII INFORMATION in gallons Galltons Tanks Manufacturer's Name Concrete con steel glass Plastic Appy <br /> New Exist ng structed <br /> Tanks Tanks <br /> Septic Tank or Holding Tank ❑ El El El <br /> Lift Pump Tank/Siphon Chamber ❑ El <br /> El 1 01 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: o S ps) MP/MPRSW No.: Business Phone Number: <br /> Ic�{F4R►� PKlr15 C4" �SBSI S- )S <br /> PI tuber's Address(street,Cit ,State,Zip�): g� ) ` <br /> 2-1 s <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑Disapproved Sanitary Permit Fee (includes Groundwater Date Issued Issuing Agent Si natur (N tamps) <br /> urcharge Fee) <br /> /�,A <br /> 041pproved [:]Owner Given Initial / ��/r_� 41 <br /> Adverse Determination <br /> X. CONDITIONS OF APPROVAL/REASONS FORDISAPPROVAL: 7 \j <br /> SBD-6398(8.11/87) - DISTRIBUTION: Original to county.One copy To: Safety&Buildings Division,Owner.Plumber <br />