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EX+i RJED PE7R m►'-j— <br /> Safety and Buildings Division <br /> SANITARY PERMIT APPLICATION 201 W.Washington Avenue <br /> V-sch6psin P O Box 7302 <br /> Department of Commerce In accord with Comm 83.05,Wis.Adm.Code 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 11 inches in size. u f t <br /> • See reverse side for instructions for completing this application s ate sanitary Permi Number �1J <br /> 37362 S <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 /> Propert Owner ame Property Location <br /> r4 }l om flN t/4 t/4,S 4 T 4CP ,N, R 15 E(or <br /> Property Owner's Mailing Address Lot Number Block Number <br /> 'P•o . Bo)< $7 <br /> City,State Zi Code Phone Number Subdivision Name or CSM Number <br /> RIJ>K M4 , 5330 (6112) lUbUitJ4 Apo 1b v-v. <br /> Il. TYPE OF BUILDING: (check one) ❑ State Owned ❑ City 7Nearest Road <br /> Public 1 or 2 FamilyDwelling-No.of bedrooms Z Iowan of hl Erlr 1C• A <br /> III. BUILDING USE: (If buildingtype is public,check all thatapply) Parcel TaxNumber(s) <br /> 1 ❑ Apartment/Condo 012 QSso og 7go <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. E] Replacement 3_ E] Replacement of 4. E] Reconnection of 5_ E] 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 /> 11 ❑Seepage Bed 21 []Mound 30❑Specify Type 41 ❑Holding Tank <br /> 12,kSeepage 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 /> Required(sq.ft.) Proposed(sq.ft.) (Gals-/day/sq.ft.) (Min./inch) Elevation <br /> '300 �Q Z 7 <br /> 3 - I q'"-S Feet `] .a Feet <br /> Capaclt <br /> VII Site <br /> FORMATION in allons Total #of Manufacturer's Name Pretab. Con- steel Fiber- plastic Exper. <br /> New Existin Gallons Tanks Concrete strutted glass App. <br /> Tanks Tanks �r <br /> Septic Tank or Holding Tank 7� 73'� ' Iz� ❑ ❑ Ell-E] ❑ <br /> Lift Pump Tank/Siphon Chamber ❑ ❑ ❑ I ❑ I ❑ ❑ <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 Signatur :IN tamps) MP/MPRSW No.: Business Phone Number: <br /> 1tj4AU0 *p;gt15 ZZSS SI '715-$66- 5 <br /> PI mber's Address(Street,City,State,Zip Code): <br /> 2Zo 35 Imo/ 1,jI- S 3 <br /> IX. COUNTY/ DEPARTMENT USE ONLY <br /> [:]Disapproved Sanitary Permit Fee (IndudesGroundwater Date Issued Issuing Age t "na <br /> Approved ❑Owner Given Initial Surcharge Fee) p <br /> Adverse Determination ✓/ <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(R.4/99) DISTRIBUTION Original to County.One copy To: Safety&Buildings Division,Owner,Plumber <br />