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Safety ancl(ids is' <br /> Vls�onsfn <br /> SANITARY PERMIT APPLICATION 201 W.Washington Avenue <br /> P 0 Box 7302 <br /> Department of Commerce In accord with Comm 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 / <br /> than 8 1/2 x 11 inches in size. li rn,2e_4 p! <br /> • See reverse side for instructions for completing this application State Sanitary <br /> /yP�Permit Numbe 3 <br /> Personal information you provide may be used for secondary purposes ❑CheclAsi�ion to prev�sapplication <br /> [Privacy Law,s. 15.04(1)(m)]. State Plan I.D.NumbRr <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION 1 <br /> Pro ertOwner Name s L Mei <br /> perty Location i <br /> 11 G rtes it C,A Stet/4,S -Z(, T3? N, R IF 6-(a) <br /> Property Own is Mail'ryB Address ^ ` Lot Number Block Number <br /> �S 33 V vl (CC( <br /> City,State �1r Zip ode (�lne ju ber Subdivision Name or CSM Number <br /> (`.J.. tCL a S- Y(o 7 <br /> II. TYPE OF B LDING: (check one) ❑ State Owned o City Ne a est Road <br /> �� �J) r <br /> Public 1 or 2 FamilyDwelling-No.of bedrooms � ❑ TownVillage OFW, �1"at t--0 d <br /> III. BUILDING USE: (If building type is public,check all that apply) Parcel TaxNumber(s) <br /> 1 ❑ Apartment/Condo I 6110 - 3&24. ©,,)- Vod <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. pg Replacement 3, ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an <br /> System ____ System ___________ TankOnly_-____ Existing System ________ Existing System <br /> B) tK A Sanitary Permit was previously issued. Permit Number �;L (p Date Issued------------- <br /> 1 �Z <br /> V. TYPE OF SYSTEM: (Check only one) <br /> Non-Pressurized Distribution Pressurized Distribution Experimental Other <br /> 11 I&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 /> 7.Gallons Per Day 2. Absorp.Area 3. Absorp.Area 4. Loading Rate IS.Perc. Rate 16. System Elev. 7. Final Grade <br /> Jf7� Req ui ed(sq.ft.) Proposed(sq.ft.) (Gals/day/sq.ft.) (Min./inch) // Elevation <br /> Z i ��iIP Feet . 6-Feet <br /> Ca act <br /> 1/II. 1 FORMATION ..Cap <br /> n gallons Total #of Manufacturer's Name Prefab. Con Steel Fiber- plastic Exper. <br /> New Existin Gallons Tanks Concrete strutted glass App. <br /> Tanks Tanks <br /> �Tor Holding Tank u -7 140 [� t�I ❑ ❑ ❑ ❑ ❑ <br /> Lift Pump Tank/Siphon Chamber I I ❑ I ❑ ❑ ❑ 1 ❑ ❑ <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:( in Plu ber s Signatur :(N amps) MP/MPRSW No.: Business Phone Number: <br /> CS o-e� 4XC ZZrzz1 71s- <br /> 6V6- o <br /> Plum er s A ss(Street, ty,State, Code : / r- <br /> v A t <br /> IX. COUNTY/ DEPARTMEN USE ONLY <br /> ❑Disapproved Sa ary Permit Fee (includes Groundwater ate IssuedIssuing Ag nt Signatur N Stamps) <br /> *Appyroved Surcharge Fee) <br /> ❑Owner Given Initial <br /> Adverse Determination I 6 <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(R.4199) DISTRIBUTION: Original to County.One copy To: Safety&Buildings Division,Owner,Plumber <br />