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r.._ C`t'1 C� <br /> SANITARY PERMIT APPLICATION SafeBureau of Building <br /> and uildi nnggWaterlSystems <br /> 201 E.Washington Ave <br /> Inaccord with ILHR 83.05,Wis.Adm.Code P.O.Box 7969 <br /> Madison,WI 53707-7969 <br /> • Attach complete plans(to the county copy only)for the system,on paper not less County <br /> than 8 12 x 11 inches in size. aQ p !d <br /> • See reverse side for instructions for completing this application State Sanitary Permit Number <br /> (mbberr <br /> The information you provide may be used by other government agency programs 3o / "' c <br /> ❑Check i)revision to previous application !�, <br /> (Privacy Law,s. t 5.04(1)(m)I. x <br /> State Plan I.D.Number Alk n <br /> 1. APPLICATION INFORMATION- PLEASE PRINT ALL INFORMATION 'J�V/'f/�L <br /> Property Owner Name Property Location <br /> AAA IEL Q 1( eg- /701/4 /7&) 1/4,S /t T _5T N, R/5L W a <br /> Property Owner's Mailin A dress Lot Number Block Number <br /> 345 "Kc s <br /> City,State ?au; ,,/� Zip Code Phone Number Subdivision Name or CSM Number <br /> �' IA 1 O ((o,z> <br /> II. TYPE OF BUILDING: (check one) ❑ State Owned ❑ ity n a Nearest Road <br /> Public 1 or 2 Famil Dwell in - No.of � <br /> bedrooms El-bedrooms / <br /> — TTo own OF <br /> III. BUILDING USE: (If building type is public,check all that apply) Parcel TaxNumber(s) <br /> 1 ❑ Apartment/Condo CR4-3///-az- wo <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 [_1 Church/School 8 ❑ Mobile Home Park 12 ❑ Service Station/Car Wash <br /> 5 ❑ Hotel/Motel 9 E] Office/Factory 13 ❑ Other: specifyIV. TYPE OF PERMIT: (Check only one box on line A. Check box on line B, if applicable) <br /> A) 1.X New 2- ❑ Replacement 3. ❑ Replacement of 4- ❑ Reconnection of 5. ❑ Repair of an <br /> ------System --------System - ------ -- --T-a-n-k OnlyExisting Sy stem Existing System <br /> - ------------------------------ <br /> B) <br /> y--- -B) <br /> ❑ 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 E P_ 4ed 21 ❑Mound 30❑Specify Type 41 [-]Holding Tank <br /> 12N 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 S. Pert. Rate 6. System.Elev. 7. Final Grade <br /> Required(sq. ft.) Proposed(sq. ft.) (GaIs/day/sq.ft.) (Min./inch) Elevation <br /> JPO 87YZ- 9D A�*Aolrh 9a.7 Feet yS,o Feet <br /> VII. TANK Capacity <br /> INFORMATION in gallons Total #of Manufacturer's Name Prefab. Site Fiber-' Plastic Exper <br /> New Existin Gallons Tanks Concrete Con- Steel glass App. <br /> Tanks Tanks strutted <br /> Septic Tank o �� o o / 1-1 <br /> —M— <br /> ❑ ❑ ❑ n <br /> Lift Pump Tank/Siphon Chamber ❑ Ej ❑ ❑ ❑ <br /> VIII. RESPONSIBILITY STATEMENT <br /> I,the undersign a responsibility for install a n of the onsite sewage system shown on the attached plans. <br /> Plumber's AYRint)� EXCAVATIO lu i nature 0Stamps) rUPI/MPRSWNo.: BusinessPhone Number: <br /> IMP <br /> �1Ve�V Una Rd. z/�75 <br /> Plumber's Add res p Code): <br /> (715)635-7482 <br /> IX. COUNTY/ DEPARTMENT USE ONLY <br /> EE]Disapproved Sanitary Permit Fee OncludeSGroundvvater ate Issue Issuing Agent gnatur (No ps) <br /> Approved ❑Owner Given Initial G� Surcharge lee) <br /> w` Adverse Determination /c/ 6 ��l✓� <br /> X. CONDITIONS OF APPROVAL/ REASONS FOR DISAPPROVAL: <br /> SHU-6398 in,05/94) DISTRIBUTION: Original to Couni ,One copy To: Safety&Ruildinys Div,--nn,Owner,Plumber <br />