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®��, Safety and Buildings Division <br /> .ISCOnS%n SANITARY PERMIT APPLICATION 21BW.ox ashingtonAvenue <br /> 7302 <br /> Department of Commerce In accord with Comm 83.05,Wis.Adm.Code Madison,WI 53707-7302 <br /> • Attach complete plans(to the county copy only)for the system,on paper not less County n �/ <br /> than 8 1/2 x 11 inches in size. .CJy/' vc to <br /> • See reverse side for instructions for completing this application State Sanitary Permit Number <br /> Personal information you provide may be used for secondary purposes E]Check if revisto revious appl3 6 n <br /> i 3 <br /> catio <br /> [Privacy Law,5. 15.04(1)(m)]. State Plan I.D.Number„ <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION t/ T <br /> PropertxOwner NameProperty Location <br /> C ,^1"01 "1/4NWi/4,50 T,39 N, R)7 E(o W <br /> Property Owner's Mailing Address1 Lot Number Block Number <br /> '.SO So, ,fir A-Ta P,/4 <br /> City <br /> St a Zi SCode Phone Number Subdivision Name or CSM Number <br /> II. TYPE OF BUILDING: (check one) ❑ State OwnedItZa 74c <br /> earestRoaPublic 1 or 2 Famil Dwellin -No.of bedrooms Town OF L t VC d /N O, V, Q <br /> III. BUILDINGUSE: (If building type is public,check all that apply) Parcel Tax Number(s) <br /> 1 ❑ Apartment/Condo ©l(p 3y33 O� 7g owa <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. rVNew 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an <br /> -----System ---- ---System------------- Tank Only ------------ Existing System ------- ExistingSystem <br /> ------- -y---- <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 /> 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 5. Perc. Rate 6. System Elev. 7. Final Grade <br /> Required (sq. ft.) Proposed(sq.ft.) (Gals/day/sq.ft.) (Min./inch) qL/ p Elevation <br /> ys-e Y00 J^— /7�D Feet 7,3 Feet <br /> Ca acct <br /> VII. TANK in gallons Total #of Prefab. Site Fiber- Exper. <br /> INFORMATION Gallons Tanks Manufacturer's Name Concrete Con- Steel Plastic P <br /> New Existing structed glass App. <br /> Tanks Tanks <br /> Septic Tank or Holding Tank 000 /000 /vo/ r✓4 Sc/O ❑ I ❑ ❑ ❑ ❑ <br /> Lift Pump Tank/Siphon Chamber ❑ I ❑ ❑ ❑ ❑ ❑ <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: oStamps) MP/MPRSW No.: Business Phone Number: <br /> At FS�o�i�r G�iJac� .2•�7G9� <br /> Plum is Address(Street,City,State,Zip Code): <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> /� ❑Disapproved S!Xitary Permit Fee (Includes Groundwater ate IssuedIssuing Age Signature(No to ps) <br /> j�Ajl' fOVed ❑ <ifl ��' ��°r<harge Fee) <br /> A A Owner Given Initial �'!.i UU 3 <br /> Adverse Determination <br /> X. CONDITIONS OF APPRONSIONS FOR DISAPPROVAL: <br /> (R.4/99) DISTRIBUTION: Original to County.One copy To: Safety a Buildings Division,Owner,Plumber <br />