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171sconsin <br /> Safety and u9�il�ings Division <br /> SANITARY PERMIT APPLICATION 201 W.Washington Avenue <br /> P O Box 7302 <br /> Department of commerce In accord with[LHR 83.05,Wis.Adm.Code Madison,WI 53707-7302 <br /> • Attach complete plans(to the county copy only)for the system,on paper not less County �r�r�e I�l-fr A3`9`18 <br /> 3 Q� rl <br /> 8 <br /> than 8112 x 11 inches in size. — ! <br /> • See reverse side for instructions for completing this application State Sanitary Per er �` R-7a <br /> Personal information you provide may be used for secondary purposes ❑cneox it r pr vm"a 11 <br /> pplication <br /> [Privacy Law,s. 15.04(1)(m)]. State Plan I.D.Nu b'eery/ <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION 3 ` 9 <br /> Property Owner NameProperty Location <br /> r v e 1/4 50 1/4,5 !C T Y0 ,N, R / E(or G&v <br /> Property wner's Mang Address l IlG f 5 v Lot Number Block Number <br /> O <br /> e So N w �f o <br /> City,State Zip Code Phone Number Subdivision Name M Numb r <br /> 7 0o NcS �L S 3 �' (7U-)(.3S -7zs C'S� <br /> II. TYPE OF BUILDING: (check one) ❑ State Owned ❑ it� Nea es oad <br /> 1:1o age S 44f`4 a I J <br /> Public 1 or 2 FamilyDwelling-No.of bedrooms TTown of /V rJ <br /> III. BUILDING USE: (If building type is public,check all that apply) Parcel TaxNumber(s) o28 yll6 D3 y/S^ <br /> 1 ❑ Apartment/Condo <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.M New 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an <br /> ystem 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 /> 11 ❑Seepage Bed 21 []Mound 30❑Specify Type 41 ❑ Holding Tank <br /> 12❑Seepage Trench 22❑In-Ground Pressure4+ G 42❑Pit Privy <br /> 13❑Seepage Pit r 43❑Vault Privy <br /> 14❑System-In-Fill <br /> VI- ABSORPTION SYSTEM INFORMATIO ..�� Q <br /> 1. Gallons Per Day 2. Absorp.Area 3. A sor�� 4. Loading Rate S. Pert. Rate 6. System Elev. 7. Final Grade <br /> y �rO Required (sq. ft.) Propo q.ft.) (Gals/day/sq. ft.) (Min./inch) Elevation <br /> t] 9�to cell y�. S Feet /)o• y ZFeet <br /> TANK Capact <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 y2yol 1 1 S C-./' ® ❑ ❑ ❑ ❑ ❑ <br /> Lift Pump Tank/Siphon Chamber 7. C I 1 ❑ ❑ ❑ ❑ ❑ ❑ <br /> VIII. RESPONSIBILITY STATEMENT <br /> 1,the undersigned,assume responsibil>4of)1stallatichif the onsite sewage system shown on the attached plans. <br /> Plumber's Name:(Print) (` P mber i n ure: amps) MP/MPRSW No.: Business Phone Number: <br /> 2737 ? 5� 376 2. 7d <br /> Plumbe 'sAddress(Street,Cit <br /> y State,Zip Code): <br /> 161 <br /> IX. COUNTY/ DEPARTMENT USE ONLY <br /> ❑Disapproved Sanitary Permit Fee (Includes Groundwater Date Issued Issuing Ag n ignatu t ps) <br /> pproved ❑Owner Given Initial r7Q© pcOrchargeFee) <br /> Adverse Determination p� <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(R.11/97) DISTRIBUTION: Original to county,One copy To: Safety&Buildings Dimion,Owner,Plumber <br />