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Safety an uildmgs ivision <br /> SANITARY PERMIT APPLICATION 201 W.Washington Avenue <br /> `Asconsin In accord with ILHR 83-05,Wis.Adm.Code P O Box 7302 <br /> Department of Commerce Madison,WI 53707-7302 <br /> 0 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. <br /> • See reverse side for instructions for completing this application state sanitary PerMa Number 3 5-3 O <br /> Personal information you provide may be used for secondary purposes ❑Check it 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 RMATI N I <br /> Pro rtyOw erNam Propert Location <br /> �ieva��vc �� e/% � /yatc ,!7/� /Pelc�r � /a��j/,14,s�6 T3 N, R/6 E(or�v <br /> Property Owner's Mailing Address, Lot Number Block N m r <br /> Cell 7 I AlegetW / ';A* <br /> Cty,St a a Zip Code Phone Number Subdivision Name or CSM Number <br /> �1/e J frr1, S� eta (7/S]35�-7958 CS/41 <br /> II. ILDIN : (check one) E] State Owned ❑ llr Nearest Road <br /> ❑ Village //��• ` <br /> Public or 2 FamilyDwelling-No.of bedrooms 3 Town of �cn o�1 /i/�� geli;' / A <br /> III. BUILDING USE: (if building type is public,check all that apply) Parcel Tax Number(s) <br /> 1 ❑ Apartment/Condo 0 `6�* - ?3c;,?, 6 _ �'s'+ 7o 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. ❑ Replacement of q. ❑ 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❑Specify Type 41 8<olding 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 15. Perc. Rate 6. System Elev. 7. Final Grade <br /> Required(sq.ft.) Propose (sq.ft.) (Gals/da /sq.ft.) (Min./' ch) Elevation <br /> Y5-6 11� /Y �i� Feet -o�V4 Feet <br /> VII. TANK Capacity Site <br /> INFORMATION in gallons Gal ons auks Manufacturer's Name ConcrePrefate con- steel g ass Plastic App. <br /> New Existin structed <br /> Tanks Tanks 1 <br /> Septic Tank or Holding Tank 000 000 j9 ❑ ❑ 0 <br /> Lift Pump Tank/Siphon Chamber ❑ El 13 <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 Stamps) MP/MPRSW No.: Business Phone Number: <br /> l ct T. ehfo G - 695 7/ <br /> Plu ber's Address(Street,City,State,Zip Code <br /> r 48 /V/ke Fwd �, Ve-�r �`�'�- ViJ: f <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑ ( udesGrundGroundwater p <br /> Issuing ntSignat ps)Disapproved Sar PermitFee <br /> rove Owner Givenvrc rgeree) <br /> pp m <br /> lnitial <br /> �7 <br /> Adverse Determination <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DI APPROVAL: <br /> SBD-6398(R.11/97) DISTRIBUTION: Original to county,One copy To: Safety&Buildings Division,Owner,Plumber <br />