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1J 1 Vl/` Safl ty and Buildings Division <br /> AsconsinSANITARY 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 /> e Attach complete plans(to the county copy only)for the system,on paper not less County <br /> than 81/2 x 11 inches in size. 42,;?—fo <br /> 0 See reverse side for instructions for completing this application StFe Sanitary Permit Number <br /> 356 33 Su <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 INF RMATI N , <br /> Property Owner Name Property Location <br /> LAVEF;ziQ1/4 1/4,S T 40 ,N, R ilk E(or) <br /> Property Owner's Mailing Address Lot Number Btork•idemrber <br /> 5'133 CRCFFATZD AV, N , I G.L- -S <br /> Cit ,State I Zip Code Phone Number Subdi 'sion Name or CSM Number <br /> II. P F BUILDING: (check one) ❑ State Owned + city Nearest Road <br /> Cj Village <br /> Public 1 or 2 FamilyDwelling-No.of bedrooms Z— Town OF C-0 L'O - R1> <br /> III. BUILDING USE: (If building type is public,check all that apply) Parcel TaxNumber(s) ��1t <br /> 1 ❑ Apartment/Condo C)zo <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 2.4^'�Replacement 3_ ❑ Replacement of 4. ❑ Reconnection of 5_ E] Repair of an <br /> _�-_System _ -_-_--_-_ -Tank OnlyExisting System----------ExlstingSystem <br /> ----------- <br /> B) E] 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 /> iX'Seepage Bed 21 ❑Mound 30 F]Specify Type 41 E]Holding Tank <br /> 1 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 Eiev. 7. Final Grade <br /> Required(sq.ft.) Pro osed s .ftJ (Gals/da /sq.ft.) (Min./inch}"" n// Q Elevation <br /> 30D "!to I ; Feet Feet <br /> a acit <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 /> ank Tanks <br /> Septic Tank or Holding Tank �� ❑ 11101 ❑ ❑ <br /> Lift 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) Plu er's Signatur :(N tamps) rz <br /> MPRSW No.: Business Phone Number: <br /> IcMl2 P ~ ZS� S- 6- 4151 <br /> Plumber's Address(Street,Ci ,State,Zip Code): . <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑Disapproved Sanitary Permit Fee (Includes Groundwater ate Issued Issuing A nt Sign ure( S ps) <br /> roved y hargeFee) L/j <br /> App ❑Owner Given Initial !/ <br /> v Adverse Determination <br /> X. CONDITIONS OF APPROVAL/REASONS FOR I PPROVAL: <br /> SBD-6398(R.11/97) DISTRIBUTION: Original to County.One copy T0: Safely&Buildings Division,Owner,Plumber <br />