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.4 <br /> u. a <br /> Safety and Buildings Division <br /> �O�riF3 SANITARY PERMIT APPLICATION Bureau of Building Water Systems <br /> 201 E.Washington Ave. <br /> In accord with[LHR 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 '510than 8 1/2 x 11 inches in size. <br /> • See reverse side for instructions for completing this application State Sanitaarry/(Pgrmit umber <br /> The information you provide may be used by other government agency programs ElcA3 kvisRfn to pre3ouslaapplication <br /> [Privacy Law,s. 15.04(1)(m)J. State Plan I.D.Numb yr� <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION <br /> Property Owner Name Prope y Loc tion <br /> 669LGgC6 o�eN�3 I1/4 L, i/4,S 3(,, T 4�o r N, R /-/ BIW <br /> Property Owner's Mailing Add ess L t Number Block Number <br /> 3609 oazeg- 2 c <br /> ICity,State Zip Code Phone Number Subdivision Name or CSM Numger <br /> ll. TYPE OF BUILDING: (check one) ❑ State Owned ❑C] villCityage crest Road <br /> Public 1 or 2 FamilyDwelling- No.of bedrooms Z-- Town OF d rT <br /> III, BUILDING USE: (If building type is public,check a I I that a pply) Parcel TaxNumber(s) <br /> 1 ❑ Apartment/Condo .:z - */a- /fe- 3G-0- 0/SOo ' <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- ❑ Reconnection of 5. ❑ Repair of an <br /> System System Tank Only Existing System Existing System <br /> ----------------------------------------------------------------------------------------------- <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 OSeepage 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. Syste Elev. 7Fil Grade <br /> . na <br /> Requir d(sq.ft.) Prop sed (sq.ft.) (Gals/day/sq. ft-) (Min./inch) 9Q Elevation <br /> 300 e7 Z 7 e''/a,- Feet 7 S Feet <br /> TANKCa cut <br /> VII. INFORMATION in gallons Total #of Manufacturer's Name Prefab. Site Con- Steel Fiber- Exper <br /> Gallons Tanks Concrete glass Plastic App <br /> New Ex Gallons strutted <br /> Tanks Tanks <br /> Septic Tankorank 800 / d00 a`J�'As� ® ❑ ❑ ❑ ❑ ❑ <br /> Lift Pump Tank/Siphon Chamber ❑ ❑ ❑ ❑ ❑ ❑ <br /> VIII. RESPONSIBILITY STATEMENT <br /> [,the undersigned s responsibility for instal ion of the onsite sewage system shown on the attached plans. <br /> Plumber's NVE P m r' Signat r :(No Stamps) LAf7MPRSW No.: Business Phone NumberNI QQU*Lina Rd : <br /> �7� & EXCAVATI 4;61yx7y <br /> Plumber's Address(StIps48p�ode): <br /> (715 83§4482 <br /> IX. COUNTY/ DEPARTMENT USE ONLY <br /> ❑Disapproved Sanitary Permit Fee (lndudeseround.aterate IssuedIssuing Agen S ature o St p <br /> pproved ❑Owner Given Initial �� �Surcharge Fee)Adverse Determination CJ <br /> X. CONDITIONS OF APPROVAL/ REASONS FOR DISAPPROVAL: <br /> SRD-6398(R.05194) DISTRIBUTION: original to CourJy,One cupy To: Safety B Buildings Dive ion,Owner,Plumber <br />