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Safety an ui&ente <br /> ion <br /> SANITARY PERMIT APPLICATION 201 W.Was <br /> N isconsin 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 n� <br /> than 8 1/2 x 11 inches in size. FMPt4GM � <br /> • See reverse side for instructions for completing this application S ate Sanitary Permi urpb� <br /> Personal information you provide By be used for secondary purposes ❑Check if revision to previous application <br /> [Privacy Law,s. 15.04(1)(m)]. State Plan I.D.Number <br /> I. APPLICATION I ORMATI N - PLEASE PRINT ALL INF RMATION <br /> Property Owner me - Property Location <br /> C) I ID rL 1/4 1/4,5 :7�4 T N, R d). E(or) <br /> Propert Ownersprailing Address Lot Number mber <br /> u, �) uh l-ece4ed .I✓. 4 <br /> City,StateZip Code Phone N er Subdivision Name or CSM Number <br /> Mt - 3l (bt2) a5- I <br /> 11. PE OF BUILDING: (check one) ❑ State Owned City Nearest Road <br /> ❑ Village <br /> Public 1 or 2 FamilyDwelling-No.of bedrooms 3 Town OF SCO 0 <br /> III. BUILDING USE: (If building type is public,check all that apply) Parcel Tax Number(s) <br /> 1 ❑ Apartment/Condo ©�o — 7 6 �� <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. Replacement 3. [:] Replacement of 4. E] Reconnection of 5_ [:] Repair of an <br /> ------System ------ _System ________ __ Tank Only-------------- ExistingSystem -_ ___ 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 /> 1114 Seepage 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 Rate 5. Perc. Rate 6. System Elev. 7. Final Grade <br /> Required(sq.ft.) Proposed(sq.ft.) (Gals/day/sq.ft.) (Min./inch) a levation <br /> I? •d Feet 49 .-5 Feet <br /> TANK Capacit <br /> VII• INFORMATION in allons Total #of Manufacturer's Name Prefab. Site Con- steel Fiber- Exper. <br /> Gallons Tanks Concrete glass Plastic App <br /> New Existin strutted <br /> Tanks Tanks <br /> Septic Tank or Holding Tank loco V I 000 ❑ ❑ ❑ ❑ ❑ <br /> Lift Pump Tank/Siphon Chamber16�� OQ _Ld / III 1vv ❑ El ❑ 1 ❑ ❑ <br /> VIII. RESPONSIBILITY STATEMENT <br /> 1,the undersigned,assume responsibility for installation of the onsite sewage system shown on the attached plans. <br /> Plumber's Name:(Print) Plumber's Signature:(No mps) MP/MPRSW No.: Business Phone Number: <br /> I Cr Asci 1-bnw>45 "" 2�-6851 tS V 6- 4151 <br /> Plumber's Address(Street, -ty,State,Zip Cod '1� �'. '548cr3 <br /> IX. COUNTY/ DEPARTMENT USE ONLY <br /> ❑Disapproved Sanitary Permit 'aqudes IssuedIssuing t Signature(N St s) <br /> pproved ❑ C! <br /> Owner Given Initial / 7�/mob �F`e> 5 <br /> Adverse Determination <br /> X. CONDITIONS OF APPROVAL/REASONS FOR ISAPPROVAL: <br /> SBD-6398(R.11/97) DISTRIBUTION: Original to county,One copy To: Safety&Buildings Division,Owner,Plumber <br />