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6SWafety and Division <br /> �Viscon5in 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 /> • Attach complete plans(to the county copy only)for the system,on paper not less County <br /> than 81/2 x 11 inches in size. t2ll a <br /> • See reverse side for instructions for completing this application State sanitary Pier i Humber <br /> Personal information you provide may be used for secondary purposes E]Check if revision o previous application <br /> [Privacy Law,s. 15.04(1)(m)]. State Plan I.D.Number <br /> L4 rig <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INF RMATION I a, <br /> PropArty Owner Name Property Location <br /> 1/4 1/4,5 5& T <br /> 126ML 40 N,R 1(e E(orig <br /> Propertybwner's ailing Address Lot Number <br /> V409 tT=(74, <br /> City,State Zip Code rWone Number Subdivision Name or CSM Number <br /> o ►J rt IV. t 13 0 <br /> 11. TYPE DIN : (check one) ❑ State Owned 11 ity Nearest Road <br /> ❑ Village <br /> El Public 1 or 2 FamilyDwelling-No.of bedrooms Z Town OF 6AXA IIJ D rt1d1101ZS LX_ 9D <br /> III. BUILDING USE: (If building type is public,check all that apply) Parcel TaxNumber(s) <br /> 1 ❑ Apartment/Condo 1 020 4_B34 &1- ctoo <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 4. E] Reconnection of 5. C] Repair of an <br /> System __ System ___ _ Tank Only ___________ Existinq_systenn __ ___ 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 2T,19.Vlound 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 r(ol <br /> . Perc. Rate 6. System Elev. 7. Final Grade <br /> Required(sq.ft.) Proposed(sq.ft.) (Gals/day/sq.ft.) Min./inch) Elevation <br /> -" 1102.341'elat .(•4 Feet <br /> VII. TANK Capacity Site <br /> in gallons Total #of Manufacturer's Name Prefab. Con- Steel Fiber- Plastic Aper. <br /> INFORMATION Gallons Tanks Concrete glass App. <br /> New Existin strutted <br /> Tanks Tan ks <br /> Septic Tank or Holding Tank * <br /> 1 El <br /> Lift Pump Tank/Siphon Chamber 00 E] ❑ 1 ❑ <br /> VIII. RESPONSIBILITY STATEMENT <br /> 1,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 St ps) MP/MPRSW No.: Business Phone Number: <br /> I4"lip "*.rt 22585 715- 89- 4S <br /> umber'sAddress(Stree City,State,Zip Codq): <br /> 2.11(00 3s Iii_ a5illl <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> Disapproved Sani Permit Fee (Includes Groundwater Date sssue� Issuing Ag ignat (No ) <br /> ll� PPPP �D 5ur< eFeel 1(11 / `CJ <br /> A roved Owner Given Initial <br /> Adverse Determination J <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 />