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ON COMPUTER/SCANNED Safety and Buildings Division <br /> SANITARY PERMIT APPLICATION <br /> Bureau of Building Water Systems <br /> 201 E Washington Ave. <br /> In accord with ILHR 83 05,Wis.Adm.Code P.O Box 7969 <br /> Madison,WI 53707-7969 <br /> • Attach complete plans(to the county copy only)for the system,on paper not less County <br /> than 8112 x 11 inches in size. Bte12NE77 97 <br /> • See reverse side for instructions for completing this application StateXnmANuum <br /> ber <br /> The information you provide may be used by other government agency programs ❑Check it revision to previous application <br /> (Privacy Law,s. 15.04(1)(m)I- State Plan I.D.Number <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION <br /> Property Owner Name Property Location <br /> DRf/iG EIY6,&L & F 1/4,S Jg T �v ,N, R ( F(or)W <br /> Property Owner's Mailing Address Lot Numb Block Number <br /> 11($0 7 /1; Aeo, e k4AC /2D <br /> City,State Zio Code - Phone Number Subdivisio ame r S mber <br /> ZMNB� w; 'Ty93o ( ) of. r� o <br /> II. TYPE F BUILDING: (check one) E] State Owned It Nearest Road <br /> Public or 2 FamilyDwelling-No.of bedrooms D V"'ag OF �Co TT Qu.SH/1 NE <br /> III. BUILDING USE: (If building type is public,check all that apply) Parcel TaxNNumbber(s) { - <br /> 1 E] /y/Apartment/Condo / /1" <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 U?5ew 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 ggl<eepage 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) Elevation <br /> I , �/ 910 Feet 99 Feet <br /> Capacity <br /> VII INFORMATION in gallons Total #of Manufacturer's Name Prefab SitCon- Steel Fiber- plastic Exper <br /> New Existin Gallons Tanks Concrete strutted glass App <br /> Tanks Tanks <br /> Septic Tank or Holding Tank 111 L���77- ❑ ❑ ❑ ❑ ❑ <br /> Lift Pump Tank/Siphon Chamber L� ❑ ❑ ❑ ❑ ❑ <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's5ignat e:(No mps) VWMPRSW No.: Business Phone Number: <br /> Cecz - Sc,�/a�E� o ob 7/5--e,3-5--3 <br /> Plumber's Address(Street,City,State,Zip Code): `, / <br /> LC A /C i(CC` r/z/1 <br /> IX. COUNTY/ DEPARTMENT USE ONLY <br /> E]Disapproved ISanitary Permit Fee (in to des Groundweter ate Issued Issuing Agent Sign at re o amps) <br /> gA roved hargeree) / j� l� <br /> pp ❑Owner Given ��J <br /> Adverse Determination <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SOD 6398(R 05(94) DISTRIBUTION'. Original to county.One copy To: Safety&Buildings Division,Owner,Plumber <br />