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ca CZr� <br /> Safety and Buildings Division <br /> SANITARY PERMIT APPLICATION 201 W.Washington Avenue <br /> VIsconsinP O Box 7302 <br /> Department of Commerce In accord with Comm 83.05,Wis.Adm.Code Madison,WI 53707-7302 t� <br /> • Attach complete plans(to the county copy only)for the system,on paper not less FState <br /> �EPermit <br /> ethan 8 12 x 11 inches in size.• See reverse side for instructions for completing this applicationaniNumber <br /> Personal information you provide may be used for secondary purposes c previous application S <br /> (Privacy Law,s. 15.04(1)(m)]- lan l.D.Nu` <br /> I. APPLI TION INF RMATI N - PLEA E PRINT ALL INF RMATION <br /> PropertyOwnerName �ropert Location �p <br /> 4 <br /> VQ Wt (: 1/4 j '6 1/4,S 2� T �0 r Nr R 1��r <br /> PopertyOwne ISM I IngA Ir ss Lot Number Block Number , / <br /> 3Z L �Or 37 ` � <br /> State ff / ZipCo a �� (�`�u ubdivisignName�orCSMt{u01r � e [1 <br /> ra��5b� Wf �- V" 7 <br /> Lily N rest Road <br /> II. <br /> TYPE BUILDING: (check one) ❑ State Owned ❑ village � �9 ) <br /> Public % 1 or 2 FamilyDwelling-No.of bedrooms Town OF W m d C i V-er `-�` <br /> III. BUILDING USE: (If building type is public,check all that apply) Parcel Tax Number(s) r- <br /> 1 ❑ Apartment/Condo ©z,1C,-,),_ J o <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 /> W. TYPE OF PERMIT: (Check only one box on line A. Check box on line B,if applicable) <br /> A) 1. New 2. ❑ Replacement 3_ E] Replacement of 4. ❑ Reconnection of 5_ E] Repair of an <br /> 'S stem 5 stem Tank Only-..............Existing System_ __ ____Existing <br /> System <br /> --y-------------ytem --------------------- <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 OMound 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 /> t[.� Required(sq.ft.) Proposed(sq.ft.) (Gals/day/sq.ft.) (Min./inch) r- ✓ Elevation <br /> �I, )b LS , Q_ I S Feet 17S-Feet <br /> VII. TANK Capacity Site <br /> in gallons Total #of Manufacturer's Name Prefab. Con- Steel Fiber- <br /> Plastic nppr. <br /> INFORMATION New Existin Gallons Tanks concrete structed glass <br /> Tank T nks 13 0 1:1 ❑ <br /> pe:pticTan;k or HoldingTank d® ❑ ❑ Elft Pk/Siphon Chamber <br /> VIII. RESPONSIBILITY STATEMENT � <br /> I,the undersigned,assume responsibi ty for installation of the onsite sewage system shown on the attached plans. <br /> Plu Br's not e: o Stamps) MP/MPRSW No.: r;7usiness Phone Number: <br /> PI m er'sName:(P int g Z� �Z �� C.S (1-�>r lig l� ,,, U 0 <br /> Plumber's Addre (StYA(reet,City,Stat Zip Code) - S , )�( _ cr �¢Y�Z <br /> Ir <br /> IX. COUNTY/DEPARTMEN USE ONLY v �/lJ �O u [ J <br /> Disa roved Sanitary Permit Fee IIn`Ic es eFee)water ate ssue Issuing A nt Signature(No Stamps) <br /> ❑ pp Surcharge Fee) <br /> Approved ❑Owner Given Initial o v C� �37 <br /> Adverse Determination <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> DISTRIBUTION: Original to County.One copy To: Safety 8 euildings Division,Owner,Plumber <br /> SBD-6398(R.4/99) ------ <br />