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CT ,F'7'� 4`�'Y11 <br /> Safety and Buildings Division <br /> VscOnsin SANITARY PERMIT APPLICATION 201 W.Washington Avenue <br /> 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 2, 3,:21,:;2_ <br /> than 81/2 x 11 inches in size. .e„ <br /> • See reverse side for instructions for completing this application ate Sanitary Permit Number <br /> � �37 <br /> Personal information you provide may be used for secondary purposes E]Check if Ision to previous application <br /> [Privacy Law,s. 15.04(1)(m)]. State Plan I.D.Number <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INF RMATI N 1 212 zz�' <br /> Proptrty O%Fner Name \ Property Location <br /> 67 r/ C N1/4 1/4,S-j 5/ T Yd ,N,R/C E(or)( <br /> Property Owner's Mailing Address Lot Number Block Number <br /> el d 6S CSX ti aN AueS- I _. ^/ 6, 4(- -2 <br /> City,State Zip Cvde Phone Number Subdivision Name or CSM Number <br /> TI—.TTPBUILDING: (check one) ❑ State Owned ❑ Lity Nearest Road <br /> ❑ Village L <br /> Public 1 or 2 Famil Dwellin -No.of bedrooms ` I Town OF 014/. 7 e U > <br /> III, BUILDING USE: (If building type is public,check all that apply) Parcel TaxNumber(s) <br /> 1 ❑ Apartment/Condo Q ;?0 t/.3 3 - J e-) <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_ Weplacement 3. ❑ Replacement of 4_ ❑ Reconnection of 5. ❑ Repair of an <br /> ____System _ __ _System T <br /> ____ _ ____ ank Only ___________ Existing System ___ _ _ ExistingSyrstem <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 [2$Aound 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 Pe77-1 <br /> 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) Ele-vation <br /> ad s-p asG /� .� '— 1`'G'8 Feet /9 Feet <br /> Ca ut <br /> VII. TANK in g lions Total #of Manufacturer's Name Prefab. Con steel fiber- Exper <br /> INFORMATION Gallons Tanks Concrete glass Plastic App <br /> New Existin strutted <br /> Tanksl Tanks <br /> Septic Tank or Holding Tank 75V 1 175-0 <br /> Lift Pump Tank/Siphon Chamber SG. s-oo E El F1 1 I-1 <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's Signature:( Stamps) MP/MPRSW No.: Business Phone Number: <br /> Plumber's Address(Street,City,State,Zp Code): <br /> .a o ," 'e 1-j w 77 s 8 <br /> IX. COUNTY/ DEPARTMENT USE ONLY <br /> ❑Disapproved Sanitary Permit Fee (includes <br /> g Groundwater ate IssuedIssuing A n ignatu a(No ps) <br /> A proved ❑Owner Given Initial �� 9 ZZ <br /> Adverse Determination <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(R.11/97) DISTRIBUTION: Original to County,One copy To: Safety&Buildings Division,Owner,Plumber <br />