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C '/ a�uildings Division <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 count �� O <br /> than 81/2 x 11 inches in size. /J <br /> • See reverse side for instructions for completing this application State Sanitary <br /> >Permit <br /> NuNumber <br /> Personal information you provide may be used for secondary purposes ❑Check i—f rev'sion to previous <br /> [Privacy Law,s. 15.04(1)(m)]. State Plan I.D.Number <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INF RMATION 1 <br /> Property Own r ame f Property Location <br /> tr C Eva SF 1/4,5 7T39 ,N, R /yE(or) <br /> Property Owner's Mailing ddFess -I ' y Lot Number Block Number <br /> Ir/�pCA) VCA <br /> ICity,State Zip Co aPhone Number Subdivision Name or CSM Number <br /> ll. TYPE DING: (check one) ❑ State Owned ❑ Ity Nearest Road <br /> ❑ VlI age <br /> Public 1 or 2 Family Dwelling-No.of bedrooms own OF w ✓S� <br /> III. BUILDINGUSE: (If building type is public,check all that apply) Parcel TaxNumber(s) <br /> 1 ❑ Apartment/Condo 60 To 1 36 <br /> 2 ❑ Assembly Hal[ 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/Mote[ 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. �tNew 2. ❑ Replacement 3_ ❑ Replacement of 4. ❑ Reconnection of 5_ ❑ Repair of an <br /> l` System System _____________ Tank Only ______________Existi ---Xt-- ________ 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 Weepage 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 /> Re wired(sq.ft.) Proposed(sq.ft.) (Gals/day/sq.ft.) (Min./inch) q Elevation <br /> S� �d o �— /S-3 Feet Y7,7 Feet <br /> Ca aut <br /> VII. TANK in allonsstiTotal #of Prefab. S1ie Fiber- Exper <br /> INFORMATION g Gallons Tanks Manufacturers Name concrete Con- Steel glass Plastic App <br /> New Exin strutted <br /> T nks Tanks Q <br /> Septic Tank or Holding Tank ®®� �490 > �7 ❑ ❑ 0 1:1 El <br /> Lift Pump Tank/Siphon Chamber El <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 Plumb r«!K/ Lure' o Stam s) MP/MPRSW No.: rBusiness Phone Number: <br /> � <br /> Plum bb'is Address(Street,City,State,Zip Code): —7 <br /> ;9 Gam( 6j -S/' <br /> IX. COUNTY/ DEPARTMENT USE ONLY <br /> ❑Disapproved Sanitary Permit Fe,R�(cludesGroundwater ate issuedIssuing Age t Si n ure mps) <br /> CriJ�urcharge Feel <br /> Approved ❑Owner Given Initial <br /> Adverse Determination <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(R.11197) DISTRIBUTION: Original to County.One copy To: Safety&Buildings Division,Owner,plumber <br />