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LL <br /> ��:: !/ ( - aT� y and Buildings Division <br /> ��Isconsin SANITARY PERMIT APPLICATION 201 W.Washington Avenue <br /> In accord with ILHR 83.05,Wis.Adm.Code P O Box 7302 <br /> Department of Commerce Madison,WI 53707-7302 <br /> a <br /> • Attach complete plans(to the county copy only)for the system,on paper not less Cou ty <br /> than 8 12 x 11 inches in size. <br /> • See reverse side for instructions for completing this application state sanitarr PermitNum <br /> er_� <br /> Personal information you provide may be used for secondary purposes El Check if revision co ore <br /> lPrivacy Law,s. 15.04(1)(m)]. State Plan I.D.Numb r <br /> I. APPLICATION INFORMATION PLEASE PRINT ALL INF RMATION I <br /> Propert Owner Name I Property Location <br /> 0/V C k 5 0� 1/4 1/4,S a T p��,N,R E [or(o <br /> Property Owner's M iling Address L OT Leeidurnber Block Number <br /> n> /Y+ <br /> City,rState Zip Code Phone Nu be Subdivision Name or CSM Number <br /> 0?3 -- <br /> II. BUILDING: (check one) ❑ State Owned Oct <br /> IY f Nearest Road <br /> ❑ Village G� <br /> Public 1 or 2 Famil Dwellin No.of bedrooms Town of e/5 0 VA)hof <br /> 111. BUILDING USE: (if buildingtype ispublic,check allthatapply) Parcel TaxNumber(s) <br /> 1 ❑ Apartment/Condo 1066 ! o2`yo7 il�00 <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. ZReplacement 3. ❑ Replacement of 4. ❑ Reconnection of 5_ ❑ Repair of an <br /> -_____System -----___System ---__ ------------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 N 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 /> �$--D Relreq.ft.) Proposed(sq.ft.) (Gals//sq.ft.) (Mi'./inch) Elevation <br /> Feet . CL7,� Feet <br /> TANK Capacity <br /> VII. INFORMATION in gallons r. <br /> Gallons Tanks Manufacturer's Name Concrete cow Steel glass Plastic App. <br /> New Existin strutted <br /> Tanks T nks <br /> Septic Tank or Holding Tank (Jod /00� <br /> Lift Pump Tank/Siphon Chamber 00 d�� El Q El Q El <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:(Print) Plumbers Signature:(N Stamps) MP/MPRSW No.: Business Phone Number: <br /> l GrJ _2:27G <br /> Plumber's Address(Street,City,State,Zip Code): <br /> 13o '/` <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑Disapproved Sanitary Permit Fee (includes Groundwater Date Issued IssuigAget Signatu a(No a ) <br /> roved <br /> surcharge F)ee) <br /> pp ❑Owner Given Initial <br /> Adverse Determination <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(R.11/97) DISTRIBUTION: Original to County,One copy To: Safety&Buildings Division,Owner,Plumber <br />