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Vis�onsin <br /> Safety and Buildings Division <br /> 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 County a J -3-32 <br /> than 8 in x 11 inches in size. BwZder <br /> • See reverse side for instructions for completing this application state Sanitary rQ it Number <br /> Personal information you provide may be used for secondary purposes ❑Check reviii i to previous application <br /> [Privacy Law,s. 15.04(1)(m)]. <br /> State Plan I.D.Number <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INF RMATI N <br /> Propert Owner Name Property Location <br /> r 1/4 1/4,S35-%T40 4v ,N, R 15 E(or)o <br /> Propert Owner's Mailing Address Lot Number MarkNumbes <br /> I S+(o <br /> Cit ,State Zip Code Phone Number Subdivision Name or C M Number <br /> c�I�tT RIO 1(U Ch 2 4 J/a!, /0 ��- <br /> II. : (check one) ❑ State Owned - ❑ Ity Nearest Road <br /> Public 1 or 2 FamilyDwelling-No.of bedrooms Z X Town of 5q C.9504 MA114M W, PD- <br /> III. BUILDING USE: (If building type is public,check all that apply) Parcel70f <br /> mber(s) — <br /> 1 ❑ Apartment/Condo <br /> . 4-2.3s' 64 'rod ) Do <br /> 2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Outdoor R to al Facility <br /> 3 ❑ Campground 7 ❑ Merchandise: Sales/Repairs 1 estaurant/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. E] Replacement g_ E] Replacement of 4. E] Reconnection of 5_ E] Repair of an <br /> ____System ________System ------------- Tank Only_____________- Existing System _________Existtnc�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 Seepage Bed 21 ❑Mound 30 Q 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-I n-Fi l l <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) levation <br /> 300 2 .4 Feet Feet <br /> ANK Ca clt e <br /> VII. INFORMATION in gallons Total #of Manufacturer's Name Prefab. Con steel Fiber- Plastic Exper. <br /> New Existin Gallons Tanks concrete structed glass App. <br /> Tank T nk r� <br /> Septic Tank or Holding Tank C��v. ❑ ❑ ❑ I ❑ ❑ <br /> Lift Pump Tank/Siphon Chamber ..7r�-� tt ❑ ❑ 1 ❑ 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: o ps) MP/MPRSW No.: Business Phone Number: <br /> Yjm,4gP 0 lAi r 5- 866 - 41SI <br /> P umber' Address Street,Ci III State,Zip Code <br /> 5493 <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> []Disapproved Sanitary Permit Fee (Includes Groundwater atte)ssue Issuing Ag Sign ure m s) <br /> proved ❑Owner Given Initial / M Surcharge Fee) <br /> Adverse Determination l <br /> X. CONDITIONS OF APPROVAL/REASONS MR DISAPPROVAL: <br /> SBD-6398(R.11/97) DISTRIBUTION: Original to County.One copy To: Safety 8 Buildings Division,Owner,Plumber <br />