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_ Safety and Buildings Division <br /> SANITARY PERMIT APPLICATION 201 E.Washington Ave. <br /> *Wscqnsin In accord with ILHR 83.05,Wis.Adm.Code P.O.Box 7969 <br /> Department of Commerce Madison,WI 53707-7969 <br /> • Attach complete plans(to the county copy only)for the system,on paper not less County' a33 <br /> than 81/2 x 11 inches in size. y/,/J e <br /> • See reverse side for instructions for completing this application State Sanitary Permit Number nQ <br /> The information you provide may be used by other government agency programs ❑Check if r � (ko C <br /> n w <br /> [Privacy Law,s. 15.04(1)(m)]. <br /> State Plan I.D.Number u, <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INF RMATION <br /> Prop rt Owner Name I / Property Location <br /> oA) /I/Jd1-1 1-- 1p s�,h/aItj6j 1/4,5 /2 T ,N, R /y E(or <br /> Property Owner's Mailing Address Lot Number Block Number <br /> o� 7 e ic G) e nJ Z/'e `— <br /> City,State Zip Code Phone Number Subdivision Name or M Number <br /> S oo��/� �✓ Jr^ ��� ( )1135=703" <br /> Ill TYPE F BUILDING: (check one) E] State Owned C] Z Nearest Road <br /> 171 Public 1 or 2 FamilyDwelling-No.of bedrooms 3 & own of c d <br /> 111. BUILDING USE: (if building type is public,check all that apply) Parcel Tax Number(s) <br /> 1 ❑ Apartment/Condo v a 2 0 <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. Replacement 3. ❑ Replacement of 4_ ❑ Reconnection of 5. ❑ Repair of an <br /> System System Tank Only Existing System _________ExistingSystem <br /> B) A Sanitary Permit was previously issued. Permit Number &9 I gs- Date Issued <br /> V. TYPE OF SYSTEM: (Check only one) <br /> Non-Pressurized Distribution Pressurized Distribution Experimental Other <br /> 11 bg,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: <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 /> 4/�G 4 73 Feet Feet <br /> Cap cit <br /> VII INFORMATION in gallons Tota[ #of Manufacturer's Name Prefab. Site Con- steel Fiber- Plastic Exper. <br /> New Existin Gallons Tanks concrete structed glass App. <br /> Tanksl Tanks <br /> Septic Tank or Holding Tank &;00 /�OC� J��� ' ❑ ❑ ❑ ❑ ❑ <br /> Lift Pump Tank/Siphon Charnber ❑ ❑ ❑ ❑ ❑ ❑ <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:(No Stamps MP/MPRSWNo.: Business Phone Number: <br /> Plum,pper's A(dress(Street,City,State,Zip Cgde): <br /> -4)0 A— 5/ _5 it E-Zip <br /> 4­15—`/92�Z <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑Disapproved nitary Permit Fee (Includes Groundwater ate Issued IlssuinjAg6nt§i@n r N amps) <br /> C 1 roved Suaharge Fee) <br /> `V p ❑Owner Given Initial 7/"VCl/V�I ,31-g <br /> Adverse Determination <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> i <br /> SBD-6396(R.11/96) DISTRIBUTION: Original to County,One copy To: Safety&Buildings Division,Owner,Plumber <br />