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\S$I, fl5,fl <br /> Safety and Buildings Division <br /> SANITARY PERMIT APPLICATION <br /> 201 W.Washington Avenue <br /> In accord with ILHR 83.05,Wis.Adm.Code P 0 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 County <br /> than 8 1/2 x 1 1 inches in size. TuRt4 'R 4-3 <br /> • See reverse side for instructions for completing this application State Sanitary Permit Number <br /> Personal information you provide may be used for secondary purposes ❑Check ii reeviiior�previous application 9. <br /> (Privacy Law,s. 15.04(1)(m)]. State Plan I.D.Number <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFO TION Li <br /> Propert Owner Name �/ I r,opert/Location <br /> {f�[`y'�g � MI C}-kACI-5 i/4 /,JtL)1/4,S J J . T 40 ,N, R 1�D E(or)O <br /> Property Owner's Mailing Address Lot Number Block Number <br /> (0171 frL l iNIAO W I-X . RV- <br /> Cit ,State Zip Code Ph ne Number Subdivisio Name or CSM Number <br /> Ar4 B R� 1, S4S 30 ('ji5)9,f,-4556 34 11cREs <br /> I. TYPE OF BUILDING: (check one) ❑ State Owned 0 City Nearest Road <br /> ❑ - 3 )0 Village unici, 14iet <br /> f NII w L1C - <br /> Public 1 or 2 FamilyDwellingNo.of bedrooms Town OF <br /> III. BUILDING USE: (If building type is public,check all that apply) Parcel Tax Number(s) <br /> _ r(s) <br /> 1 ❑ Apartment/Condo �/ — c) _ c�.7 <br /> 2 ❑ Assembly Hall 6 0 Medical Facility/Nursing Home 10 0 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 /> 1 1ASeepage 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 ired (sq. ft.) Proposed (sq.ft.) (Gals/day/sq.ft.) (Min./inch) Elevation <br /> �-SQ �"1<.3 `t .� .1 9�,2 Feet 9%1 Feet <br /> Capacity <br /> VII. IFORMATION in gallons Total #of Manufacturer's Name Prefab. Site <br /> Con- Steel fiber- Plastic Exper <br /> New Existing Gallons Tanks Concrete strutted glass App. <br /> Tanks Tanks <br /> Septic Tank or Holding Tank IOW X. <br /> � <br /> El El El El El <br /> Pump Tank/Siphon Chamber / ❑ ❑ ❑ ❑ ❑ <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:( o S ps) MP/MPRSW No.: Business Phone Number: <br /> MAABO AD Pe-)45 %,�w.& 4 275AS'1 7iSS Se6- 457 <br /> 'PI nber's Address(Street,City, tate,Zip Code): <br /> 211!�o vyy 35- It JJ$sT t . .54$43 <br /> / <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑Disapproved Sanitary Permit Fe (Includes Groundwater Date Issued Issuing a ign ur mps) <br /> ,�. Surcharge Fee) <br /> Q Approved ❑Owner Given Initial , ��o,�� /r%-5-cid � <br /> �� Adverse Determination / <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> ..__ ____ ._ ...__. DISTRIBUTION: Oriainal to County,One copy To: Safety&Buildings Division,Owner,Plumber <br />