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t.�Safe and Buildings Divisit <br /> SANITARY PERMIT APPLICATION 201 W.Washington Avenue) <br /> Wisconsin 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 /> oZ 179 <br /> than 8 1/2 x 11 inches in size. <br /> • See reverse side for instructions for completing this application S ate Sanitary Permit Number <br /> Personal information you provide may be used for seconds U 3o 3 9 '3 <br /> y p y secondary purposes ❑Check if revision to previous application <br /> [Privacy Law,s. 15.04(1)(m)]. State Plan I.D.Numbers <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INF RMATION IN <br /> Property O ner O1J 1/4 <br /> Name Property LocationS 7 T G�p ,N, R 14E(or W <br /> Property Owner's Mailing Address eld <br /> S 1. <br /> q �/11 .�jLot Number Block Number <br /> _-55 <br /> N. PIKE . RD. <br /> City,State Zip Code Phone Number SubdivisionN me or CSM Number <br /> I. BUILDING: (check one) ❑ State Owned iml❑ Ity Nearest Road <br /> Public 1 or 2 Family Dwelling-No.of bedrooms 2 Ti Village own OF.aC ar .' • WA <br /> x N <br /> 111. BUILDING USE: (If building type is public,check all that apply) Parcel Ta__.�� Soo <br /> 1 ❑ Apartment/Condo O2 3-75 0 <br /> 2 ❑ Assembly Hall 6 ❑ Medical Facility/Nur(ingHome10 ❑ Outdoor Recr ional Facility <br /> 3 ❑ Campground 7 ❑ Merchandise: Sales/ rs 11 ❑ Resta Bar/Dining <br /> 4 ❑ Church/School 8 ❑ Mobile Home Park ervice 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. ❑ Reconnection of 5. ❑Repair of an <br /> Sntem _ System------------- Tank Only ............. Existing System ________ ExistlnoSystem <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 :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) E evation <br /> 3D p Zq �(-: Zo7r`–— z.:1 Feet 5.0 Feet <br /> TANK Capacity <br /> VII. r. <br /> INFORMATION in gallons Gallons Tanks Manufacturer's Name Concrete core- Steel glass Plastic Appp- <br /> New Existingstructed <br /> Tanks Tanks ���� <br /> Septic Tank or Holding Tank Soo Soo 45 1<fll1lii,/ <br /> apt I ❑ 0 n <br /> Lift Pump Tank/Siphon Chamber I I ❑ ❑ El Ej ❑ <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 ignature:(No to ) MP/MPRSW No.: Business Phone Number: <br /> Ie-4AKD 1d5r <br /> Plu ber's Address(Street,City, tate,Zip Code): <br /> -01 . <br /> IX. COUNTY/DEPARTM LINT USE ONLY <br /> ❑Disapproved Sanitary Permit Fee llndudesGroundwater Date Issued Issuing A :enXignat <br /> a St ps) <br /> .roved Surcharge Fee) <br /> pp ❑Owner Given Initial �5�� //–,7 0_9rf� <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 a Buildings Division.Owner,Plumber <br />