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` _n cclt7� <br /> SANITARY PERMIT APPLICATION 201Qty E.Wasand BngtonAvuildins einion <br /> Viconsin In accord with ILHR 83.05,Wis.Adm.Code P.O.Box 7969 <br /> Department of Commerce Madison,WI 53707-7969 <br /> • Attach complete plans(to the county copy only)for the system,on paper not less Coun <br /> than 8 112 x 11 inches in size. "atJC� (� a <br /> • See reverse side for instructions for completing this application state sanitary Permit Number <br /> 33�4ag <br /> The information you provide may be used by other government agency programs ❑Check if revision to previous application <br /> [Privacy Law,s. 15.04(1)(m)). <br /> State Plan I.D.Number <br /> I. APPLICATION INFORMATION- PLEASE PRINT ALL INFORMATION <br /> Property wpe NameProperty ocation <br /> z3)1 � ,) Jj1/4W 1/4,S �� TY' ,N, RI�E(or�l <br /> Property Owner's MailingAddr s i Lot Number Block Number <br /> ,35,11 <-- -5 circ /� — <br /> City,State, Zip Code Phone Number Subdivision Name or CSM Number <br /> /11 iuCla .Sc S, (70 7) 337-503Y — <br /> Il. TYPE OF BUILDING: (check one) ❑ State Owned p vli(age Nearest Road <br /> Public 1 or 2 FamilyDwelling-No.of bedrooms o2 Town OF�,4 � >° )Ake- <br /> Ill. BUILDINGUSE: (If building type is public,check all that apply) Parcel TaxNumber(s) <br /> 1 ❑ Apartment/Condo C) I Y_ a oZ)(p— 0) <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 ❑Seepage Bed 21 ❑Mound 30❑Specify Type 41 ❑Holding Tank <br /> 12 KSeepage 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) Elevation <br /> 00 o 7� 375— ` 75-` - Feet Feet <br /> TANK Ca acft <br /> VII INFORMATION in gallons Total #of Manufacturer's Name Prefab Site Con- steel Fiber- plastic Exper. <br /> New Existin Gallons Tanks Concrete strutted Blass App. <br /> Tanks Tanks <br /> �[[ <br /> Septic Tank or Holding Tank ❑ ❑ ❑ ❑ ❑ <br /> Lift Pump Tank/Siphon Chamber ❑ ❑ ❑ ❑ ❑ ❑ <br /> VIII. RESPONSIBILITY STATEMENT <br /> I,the undersigned,assume responsibility for installation of the onsite sewage system shown on the attached plans- <br /> Plumber's Name:(Pri <br /> lans.Plumber'sName:(Pri ) / Plumber's Signature:(No Stamps) MP/MPRSWNo.: BUsinessPhone Number: <br /> c/ u��o`n7 <br /> Plumber's Ar dress(Street,City,State,Zip Code): <br /> ffd X / _ Si'r e- �✓ �' � 7� <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑Disapproved Sanitary Permit Fee (Includes Groundwater ate IssuedIssuing ent Signature(No Stamps) <br /> Approved ❑OwnerGivenInitial )�S- ,� SurchargeFee) /n <br /> Adverse Determination U'U I V `�' v� <br /> X. C NDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(R.11/96) DISTRIBUTION: Original to County.One copy To: Safety d Buildings Division,Owner,Plumber <br />