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Safety and Buildings Division <br /> SANITARY PERMIT APPLICATION 201 E.Washington Ave. <br /> �Sconsin In accord with ILHR 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 Cou / <br /> than 8 t2 nt ,r !O x 11 inches in size. / <br /> • See reverse side for instructions for completing this application State Sanitary Permit Nu ber <br /> The information you provide may be used b other government agency programs ;j1rr <br /> y p y y g q y p g ❑Check I revision to previous application <br /> [Privacy Law,s. 15.04(1)(m)]. State Plan I.D.Nu er <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INF RMATION <br /> Property Oer Name Property Location <br /> nnv St"-/Tin ki jf1/4 1115 1)4,S ZS' T3 8" ,N, R /7 E(or) <br /> Property Owner'i Mailing Address Lot Number Block Number <br /> 9 o vn-r <br /> City,State Zip Code I Phone Number Subdivism o CS umb <br /> X690 )3 Y- /6 . V <br /> I. TYPE OF BUILDING: (check one) ❑ State Owned 'll.tyyage Nearest Road <br /> rl S S <br /> Public 1 or 2 FamilyDwelling-No. of bedrooms � ❑ ViTown OF /%)+h-1 0410 3 <br /> III. BUILDING USE: (If building type is public,check all that apply) Parcel TaxNumber(s) <br /> 1 ❑ Apartment/Condo OO�_ ��� _ HOZ 4-17,10 <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 __ -_ 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 Fg]Seepage Bed 21 []Mound 30❑Specify Type 41 ❑Holding Tank <br /> 12❑Seepage Trench 22❑[n-Ground Pressure 42❑Pit Privy <br /> 13❑Seepage Pit Z X7 Z_ 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 S. Perc. Rate 6. System Elev. 7. Final Grade <br /> Required (sq. ft.) Proposed(sq.ft.) (Gals/day/sq.ft.) (Min./inch) Elevation <br /> $/a 7 �� �' Feet 9/, g Feet:y0o '35-7 <br /> TANK Capaclt <br /> VII INFORMATION in allons Total Tanks Manufacturer's Name Comsat. con steel glass Plastic Aper. <br /> allonNew Existin structed <br /> Tanks Tanks <br /> Septic Tank or Holding Tank Zoo ZOO ® ❑ ❑ ❑ 1:1 ❑ <br /> Lift Pump Tank/Siphon Chamber El El ❑ ❑ 1 ❑ ❑ <br /> VIII. RESPONSIBILITY STATEMENT <br /> I,the undersigned,assume responsibility for instaIj&iob Otoe onsite sewage system shown on the attached plans. <br /> Plumber's Name:(Print) PI is e:(N St m s MP/MPRSW No.: Business Phone Number: <br /> rad 22 7 71r- ?49 4X9,5+ <br /> [ _ <br /> Plumber's Ac dress(Street,City,State,Zip Code): <br /> N1_t✓ <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> AP ❑Disapproved Sanitary Permit Fee (Includes Groundwater a e ssue Issuing gen ignature(N ps) <br /> roved Surcharge Fee) <br /> []Owner Given Initial ` <br /> Adverse Determination <br /> X. CONDITIONS OF APPROVAL/REASONS FOIT DISAPPROVAL: <br /> SBD-63M IRA 1/96) DISTRIBUTION: original to County.One copy To: Safety 6 Buildings Division,Owner,Plumber <br /> 1 , <br />