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• _• <br /> 0 i <br /> Safety and Buildings Division <br /> V <br /> se®nsin SANITARY PERMIT APPLICATION 201P 0 e x Washington Avenue <br /> 7302 <br /> Department of Commerce In accord with Comm 83.05,Wis.Adm.Code Madison,WI 53707-7302 <br /> • Attach corhplete plans(to the county copy only)for the system,on paper not less County3 <br /> than 81/2 x 11 inches in size. 4,fes et) <br /> • See reverse side for instructions for completing this application State Sanitary Permit Nwnber <br /> ON COMPUTER/SCAN 'a" <br /> 566 <br /> Personal information you provide may be used for secondary purposes ck If revision to previous application <br /> 1. <br /> [Privacy Law,s. 15.04(1)(m)]. State Plan I.D.Number <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION '.--z„..---- <br /> Property Owner Name AProperty Location PG <br /> C, fr" e.-ell e r 5 c,rL} Nom,+ 1/4,,� 1/4,S / T 3 7 ,N, R/ E(or)(/D <br /> J <br /> Property Owner's Mailing Adpress Lot Number Block Number <br /> 7i o L do 6A el, <br /> City,Statg Zip Code Pone Num er Subdivision Name or CSM Number <br /> /iUoI '& mom, 5. 5-303 (0(215/6-1,.° •7 <br /> II. TYPE OF BUILDING: (check one) 0 State Owned ❑ CityNearest Road <br /> ❑ Public a 1 or 2 Family Dwelling- No.of bedrooms — gown OF 7F4--elm 4-74-Kr?445/2r�,� G�.r4",:a1 Pr! <br /> III. BUILDING USE: (If building type is public,check all that apply) Parcel Tax Number(s) <br /> 1 ❑ Apartment/Condo O 3 9 /50 / 0 .2 6 `O <br /> 2 0 Assembly Hall 6 0 Medical Facility/Nursing Home 10 0 Outdoor Recreational Facility <br /> 3 0 Campground 7 0 Merchandise: Sales/Repairs 11 0 Restaurant/Bar/Dining <br /> 4 0 Church/School 8 0 Mobile Home Park 12 0 Service Station/Car Wash <br /> 5 0 Hotel/Motel 9 0 Office/Factory 13 0 Other: specify <br /> IV. TYPE OF PERMIT: (Check only one box on line A. Check box on line B,if applicable) <br /> A) 1. 15r New 2. 0 Replacement 3. 0 Replacement of 4_ ❑ Reconnection of 5_ 0 Repair of an <br /> - System System Tank Only Existing System Existing System <br /> B) 0 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 0 Seepage Trench 22 0 In-Ground Pressure 42 0 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 /> C7 <br /> Req�uiireedt(ssq.ft.) Proposed(sq.ft.) (Gals/daY/sq.ft.) (Min./inch) C� EI vation <br /> 6 c, v - 7) / E. Feet / Feet <br /> ANK Capacity <br /> VII. FORMATION <br /> in gallons Total #of Manufacturer's Name Prefab. Con- Steel Fxper. <br /> Site <br /> New Existing Gallons TanksConcrete strutted glaiber-ss Plastic EApp. <br /> Tanks Tanks <br /> Septic Tank or Holding Tank 75-0 / /�!'-�/ ...1 S, 0 0 0 0 0 <br /> Lift Pump Tank/Siphon Chamber -5-Y30 00 ❑ ❑ ❑ ❑ ❑ <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:( Stamps) MP/MPRSW No.: Business Phone Number: <br /> `)A-ck k q 6 X 44/m ex l7644. ?.-76 / , `P"Z <br /> Plumber's Address(Street,City,Sta?,Zip Code): <br /> th9 _s— cf 5-/,^e---) 4.---J V. . 7� <br /> IX. COUNTY/ DEPARTMENT USE ONLY <br /> ❑Disapproved Sanitary Permit Fee (Includes Groundwater Date Issued Issuing Ag t Sign u (4f :mps) <br /> proved ❑Owner Given Initial f CT <br /> 75.-- cv �harge Fee) <br /> 54°.'°° <br /> o'(, +� II <br /> Adverse Determination ! ,, ,., <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br />