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... . .. _ . .. __... . . .... . . . .. . . ... . .... _.. <br /> Safety and Buildings Divi on <br /> SANITARY PERMIT APPLICATION 201 W.Washington Avenue <br /> Visconsin 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. { a n <br /> • See reverse side for instructions for completing this application State Sanitary Permit <br /> N�u(/mlbe <br /> Personal information you provide may be used for secondary purposes ❑Check revision p e l application <br /> IPrivacy Law,s. 15.04(1)(m)]. <br /> State Plan I.D.Number <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INE ORMATI N <br /> Property Owner Name n Property Location <br /> 't,JAA j � 1/a 1/a,5 1/1 rt, ej3 T yU ,N, R / E(or)� <br /> Property Owner's Mailing Address p Lot Number Block Nu ber <br /> a v ;S /1 ;-Mr/t't 7. <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> tL;/2 C S (✓i <br /> II. TYPE OF BUILDING: (check one) ❑ State Owned ❑ itNearest Road <br /> ❑ 6 <br /> Public 1 or 2 FamilyDwellingVillage- No.of bedrooms Town of �u <br /> .J r� <br /> III. BUILDING USE: (If building type is public,check all that apply) Parcel TaxNumber(s) hh � <br /> 1 F1Apartment/Condo C�Obed— x-1133—Vi'�L'(y�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_ Q New 2.;g Replacement 3. ❑ Replacement of 4. Q Reconnection of 5. Q Repair of an <br /> ____System ___ ___System _____________ TankOnly---------------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 /> 12 Q Seepage Trench 22❑In-Ground Pressure 42❑Pit Privy <br /> 13❑Seepage Pit ALn vatilt P i y'� <br /> 14❑System-In-Fill I /n 4 4s / Ct <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) c� Elevation <br /> J 6 l 3 . `/y A /�I Feet `f�v U Feet <br /> Cap act <br /> VII FORMATION in allons Total #of allons Tanks Manufacturer's Name Prefab- Con- Steel glassSite Fiber- Plastic Aper <br /> New ExistingGConcrete structed PP' <br /> Tanks Tanks <br /> Septic Tank or Holding Tank 10601 Q 1 lovo ❑ ❑ ❑ ❑ <br /> Lift Pump Tank/Siphon Chamber I 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) PI tuber'sgnature:(N Stamps) MP/MPRSW No.: Business Phone Number: <br /> I]1 — - as 3337 a3 <br /> Plumber's Address(Street,Cit ,State,Zip Cod <br /> L� � <br /> IX. COUNTY/ DEPARTMENT USE ONLY <br /> p, <br /> []Disapprove itary Permit Fee (includes Groundwater ate ssue IssuingreSignas) <br /> m►iCpproved ❑Owner GivenInitial / �s �a`geF�ei /��_^ <br /> v Adverse Determination ( y <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> cnn_c�Ialx rIa ro'n DISTRIBUTION: Original to County,One copy To: Safety&Buildings Division,Owner,Plumber <br />