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Wafety and Buildings Division <br /> SANITARY PERMIT APPLICATION 201 W.Washington Avenue <br /> V6onsin In accord with ILHR 83.05,Wis.Adm.Code P O Box 7302 <br /> Department of Commerce Madison,WI 5 707-7302 <br /> • Attach complete plans(to the county copy only)for the system,on paper not less County �l <br /> than 8 112 x 11 inches in size. <br /> • See reverse side for instructions for completing this application ate sanitary Per it N mber <br /> 33: Z <br /> Personal information you provide may be used for secondary purposes ❑Check if revision to previous application <br /> (Privacy Law,s. 15.04(1)(m)]. State Plan I.D.Number <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION <br /> Property Owner Name Property Location <br /> CARO4 0 1/4 1/4,5 T N,R tl E(or�N <br /> Property Owner 5 Mailin Address Lot Number BI k umber <br /> City,State I Zip Code Phone Number Subdivision Name or CSM Number <br /> a t^I ( 15K95 M95 <br /> I. TYPE UF BUILDING: (check one) ❑ State Owned Cits Nearest Road <br /> Public 1 or 2 FamilyDwelling-No.of bedrooms 2 °U.Tolwn of Suitt _a Rp' <br /> Ill. BUILDI USE: (If building type is public,check all that apply) Parcel Tax Number(s) <br /> 1 C] Apartment/Condo QZs 9175, of " <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. C] Replacement 3_ E] Replacementof 4. ❑ Reconnection of 5. E] Repair of an <br /> X System -____ _ SystemTank Only <br /> -_______ _ y______________ Existing System <br /> 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 /> 1136 Seepage 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: p! 7 <br /> 1.Gallons Per Day 2. Absorp.Area 3. Absorp.Area 4. Loading Rate 5. Perc. Rate 6. System E ev. 1 7. Final Grade <br /> Required(sq.ft.) Pro osed(sq.ft.) (Gals/day/sq.ft.) (Min./inch) E vation <br /> 300 1 400e. �— Feet CH. 4 Feet <br /> VII. TANK Capacity Site <br /> in gallons Total #of Manufacturer's Name Prefab. Con- Steel Fiber- plastic Exper. <br /> INFORMATION New E0istin Gallons Tanks Concrete strutted glass App. <br /> T nks Tank <br /> Septic Tank or Holding Tank 11AL <br /> 11 <br /> Lift Pump Tank/Siphon Chamber EJ 11 ❑ ❑ Ej <br /> Vlll. 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: oS ps) MP/MPRSWNo.: Business Phone Num be r: <br /> I o $5' . <br /> PI mber's Address(Street,City tate,Zip Code): <br /> 6a 35 �i <br /> IX. COUNTY/ DEPARTMENT USE ONLY <br /> ❑Disapproved 1-149 <br /> tary Permit Fee (Includes Groundwater ate IssuedIssuing ZA; <br /> nt gnature o St <br /> rovedIIpsurcharge Fee) <br /> �->'r(p ❑Owner Given Initiall.JI�JY`l\Adverse Determination +J <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(R,11197) DISTRIBUTION: Original to County.One copy To: Safety i1 Buildings Division,Owner,Plumber <br />