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6'n. C� Safety d Buildings Division <br /> SANITARY PERMIT APPLICATION 201 W.Washington Avenue <br /> %6onsin In accord with(LHR 83.05,Wis.Adm.Code P O Box 7302 <br /> Department of Commerce Madison,WI 53707-7302 <br /> • Attach complete plans(to the county copy only)for the system,on paper not less County �� S <br /> than 81/2 x 11 inches in size. 1Z (0 <br /> • See reverse side for instructions for completing this application State Sanitary.Urmit Number <br /> 9K6234 <br /> Personal information you provide may be used for secondary purposes ❑Check if revision to previous application <br /> (Privacy Law,s. 15.04(1)(m)). State Plan I.D.Number . <br /> I. APPLICATION INFORMATION- PLEASE PRINT ALL INF RMATION 1 <br /> Property Owner Name Property Location <br /> 1/4 1/4,S �3 T N, R 15 E(or)W <br /> Propert Owner's ailing Address Lot Number Block Number <br /> W AV. iJ•�- $ 1 11 <br /> Cit ,State Zi Code Phone Number Subdivision NaTe or CSM Numb •� <br /> �A 1J • 5P5 (Lrt bo- e a <br /> 11. TYPE OF BUILDING: (check one) ❑ State Owned ❑ Ity r4PArPqt1Rcsad <br /> Public Tg 1 or 2 Family Dwelling-No.of bedrooms Z ❑ TownVillag"0 F <br /> OF SIRcKSo1J 1��i4tx}tiJD TR.Irtlr� <br /> III. BUILDING USE: (If building type is public,check all that apply) Parcel Tax Number(s) <br /> 1 ❑ Apartment/Condo 012 9500 O$ • <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_ E] Replacement of 4. E] Reconnection of 5. [:] Repair of an <br /> ____System _____ 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[1 Specify Type 41 []Holding Tank <br /> 12Seepage Trench 22 E]In-GroundPressure 42 Pit Privy <br /> 13'Q 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.) Propos d sq.ft.) (Gals day/sq.ft.) (Min./inch) O Elevation <br /> 300 r — 7• g Feet Feet <br /> TANK Ca cit <br /> VII. FORMATION in gallons Total #of Manufacturer's Name Prefab. Con- Steel Site Fiber- Plastic Aper. <br /> New ExistingGallons Tanks Concrete structed glass App. <br /> Tanks Tanks I <br /> Septic Tank or Holding Tank —' GP ❑ ❑ ❑ ❑ ❑ <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:(Print) Plumber's Signature:(No tamps) MP/MPRSW No.: Business Phone Number: <br /> ukgao ,( 22S$Sl fS- 6- <br /> PI ber s Address(Street City,State,Zip Code) <br /> el <br /> L <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> E]Disapproved Sanitary Permit Fee (Includes Groundwater ate Issued Issuing nt Si ture( mps) <br /> roved Surcharge Fee) <br /> I�.App ❑Owner Given Initial <br /> C�/J Adverse Determination _lt <br /> X. CONDITIONS OF APPROVAL/REASONS FO DISAPPROVAL: <br /> SBD-6398(R.11/97) DISTRIBUTION: Original to county.One copy To: Safety 8 Buildings Division,Owner,Plumber <br />