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011 vlyyw <br /> Safety and B dings Division <br /> SANITARY PERMIT APPLICATION 201 E.Washington Ave. <br /> Vsconsin In accord with ILHR 83.05,Wis.Adm.Code P.O.Box 7969 <br /> Departmentof Commerce Madison,WI 53707-7969 <br /> • Attach complete plans(to the county copy only)for the system,on paper not less County <br /> than 8 1/2 x 11 inches in size. <br /> • See reverse side for instructions for completing this application S ate sanitary Permitt1N�/�umbier <br /> The information you provide may be used by other government agency programs E]Ch3it 3ori to previous application <br /> [Privacy Law,s. 15.04(1)(m)]. - State Plan LD.Number <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INF RMATI N <br /> Property Owner Name Property Location <br /> .C . Ct-ICS T 1/4 1/4,5 T40 N, R js E(o W <br /> Property Owner's Mailing Address Lot N mb r Block Number <br /> E. v d- � � <br /> C ,Sta a Zi Code Phone Number Su ivision Name or CSM Numb <br /> itRAPLE Ofl n(- �5 104q (6 2 w nl ADD .v <br /> II. TYPE B IL ING: (check one) ❑ State Owned ° vlage � I Nearest Road D <br /> El Public 1 or 2 FamilyDwelling-No.of bedrooms 3 Town of1AA � <br /> III. BUILDING USE: (If buildingtype is public,check all thatapply) Parcel TaxNumber(s) <br /> 1 ❑ Apartment/Condo NZ q350 N Soo 400 <br /> 2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Outdodr 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. E] Replacement of 4. ❑ Reconnection of 5. E] Repair of an <br /> ------System --- ----System ---- ---- -- Tank Only ---- Existing System 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)1 Seepage Bed 21 E]Mound 30 E]Specify Type 41 E]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 1 3. Absorp.Area 4. Loading Rate 5. Perc. Rate 6. System Elev. 7. Final Grade <br /> O Req iredd ((sq.ft.) Pro s Esq.ft.) (Gals/day/sq.ft.) (Min./inch) levation <br /> Z7 Feet .Z Feet <br /> VII. TANK Capacity <br /> In 9-7110 S TOtal #Of Prefab. Site Fiber- Exper. <br /> INFORMATION Gallons Tanks Manufacturers Name concrete cO" Steel Plastic <br /> New Existin structed glass App. <br /> Tanks Tanks <br /> Septic Tank or Holding Tank Qo 1<4 W 21 ❑ ❑ ❑ ❑ ❑ <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)J� Plumber's <br /> lans.Plumber'sName:(Print) Plumber's Signature: No mps) MP/MPRSWNo-: Business Phone Number: <br /> OFPAI <br /> PI tuber's Ar dress(Street,City,State,Zip Code): <br /> LTJ— I <br /> . S49I <br /> IX. COUNTY/DEPART NT USE ONLY <br /> � ❑Disapproved Sanitary Permit Fee (includes Groundwater at sue issuing ge Signat re ps) <br /> 9A^ roved r harge Fee) — <br /> pp ❑Owner Given Initial 7-�� � <br /> Adverse Determination <br /> X. CONDITIONS OF APPROVAL/REASO S FOR DISAPPROVAL: <br /> SBD-6986 IRA 1/96) DISTRIBUTION: Original to County,One copy To: Safety 6 Buildings Division,Owner,Plumber <br />