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Safety and Buildings Division <br /> .,��consin SANITARY PERMIT APPLICATION 201 E.Washington Ave. <br /> In accord with[LHR 83.05,Wis.Adm.Code P.O.Box 7969 <br /> Department of Commerce Madison,WI 53707-7969 <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. 7 <br /> 0 See reverse side for instructions for completing this application state Sanitary Per it her <br /> The information you provide maybe used by other government agency programs (,// ❑Check kiitrerevision to previous application <br /> [Privacy Law,s. t 5.04(t)(m)). S�2- 'v%Z State Plan LD.Number <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION / <br /> Pro Owner Na,me Property Location <br /> t <br /> /4,S T C6 ,N, R/4 F.4r*)W <br /> Probe Owner's Mailing Address Lot Number Block Number <br /> 6 �' _ ._ <br /> Cit ,Stat Zi Coe Phone Number Subdivision Name or CSM Number <br /> lGJ� ( ) 7 <br /> . TYPE F BUILDING: (check one) E] State Owned ity Nearest Road 1 <br /> ❑ Village <br /> Public 1 or 2 Famil Dwelling-No. of bedrooms Town OF Lel r L / s <br /> III. BUILDIN USE: (If building type is public,check all that apply) Parcel Tax Number(s) /,-13 <br /> 1 ❑ Apartment/Condo ©6 i3^�J d&_ G9C6 <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_ ❑ Reconnection of 5. ❑ Repair of an <br /> System _ System ____ ___ ___ Tank Only .............Existing System __ ___ ExistingSystem <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 ❑Holding Tank <br /> 12A Seepage Trench 22❑In-Ground Pressure 42❑Pit Privy <br /> 13❑Seepage PitI 43 E]Vault Privy <br /> 14❑System-In-Fill 4 rs— /� <br /> Vi. ABSORPTION SYSTEM INFORMATION: <br /> 1. Gallons Per Day2. Absorp.Area 3. Absorp.Area 4. Loading Rate 5.Perc. Rate 6. System Elev. 7. Final Grade <br /> �� Requir� q.ft.) Prot I posed(sq.ft.) (Gals/day/sq.ft.) (Min./inch) 3 n EI vation <br /> / j Feet �, 9 <br /> CapacityFeet <br /> VII. TANK in llonTotal #of Prefab. Site Fiber- Exper <br /> INFORMATION g Gallons Tanks Manufacturers Name concrete Con- steel glass Plastic App <br /> New Existin strutted <br /> Tanks Tanks r7� <br /> Ic Tan r Holding Tank K.7, El El E <br /> Lift Pump Tank/Siphon Chamber4 ❑ El Ej ❑ El ❑ <br /> VIII. RESPONSIBILITY STATEMENT <br /> I,the undersigned,assume responsibility for installation of the onsite sewage system shown on the attached plans. <br /> Plumy er's Name:(Print) / Plumb is gnature:( St ps) MP/MPRSW No.: Business Phone Number: <br /> G/16ir 7-2- <br /> A/C_ <br /> 2 fit!7 <br /> Plu e.'s Address(Street CPy <br /> ,State,Zip d � /'/ <br /> IX. COUNTY/DEPARTMENT USE ONLY /r <br /> ❑Disapproved Sanitary Permit Fee (Includes Groundwater ate IssuedIssuing A nat a(No am <br /> loved Surcharge Fee) �y <br /> p []Owner Given Initial /� �2-41,Tte <br /> t�v Adverse Determination <br /> X. CONDITIONS OF APPROVAL/REASONS FOFt DISAPPROVAL: <br /> SBD66398(R.11/96) DISTRIBUTION: original to County,One copy To: Safety 8 Buildings Division,Owner,Plumber <br /> f <br />