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Safety add Buildings Division <br /> SANITARY PERMIT APPLICATION 201 W.Washington Avenue <br /> Visconsin' <br /> In accord with ILHR 83.05,Wis.Adm.Code P O Box 7302 <br /> Department of Commerce Madison,WI 53707-7302 <br /> • Attach complete plans(to the county copy only)for the system,on paper not less Co my <br /> than 8 1/2 x 11 inches in size. (� <br /> • See reverse side for instructions for completing this application SKte Sani�PermitNumber . <br /> Personal information you provide may be used for secondary purposes ❑Check i mvis5n to previous application <br /> [Privacy Law,s. 15.04(1)(m)]. State Plan I.D.Number if <br /> I. APPLICATION INFORMATION- PLEASE PRINT ALL INF RMATI N <br /> PropertLpwner Name Property Location <br /> 1/4 1/4,S 3 T � ,N,R 5E( )W <br /> Property Owner's Mailing Addresi Lot Number <br /> u LOP AV- 14. 1 � L <br /> City,State Zip Code T6oneNumber Subdivisi nName orCSM Number <br /> MJ_ S 46) > 2 cS - P. <br /> II. TYPE OF BUILDING: (check one) ❑ State Owned Cit�ge Nearest Road <br /> 3 <br /> Public 1 or 2 Famil Dwellin ❑VII a-No.of bedrooms Town OF �5� '-941eE <br /> III. BUILDIN USE: (If building type is public,check all that apply) Parcel Tax Number(s) �, <br /> 1 ❑ Apartment/Condo D 12 ,}�Lj 05 <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_ E] Replacementof 4. E] Reconnection of 5. C] Repair of an <br /> --System -__ /-- System Tank Only .............Existinqsyst-- -------- E----c-System <br /> ---------------------- <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 /> 11Seepage Bed 21 ElMound 30❑Specify Type 41 C]Holding Tank <br /> 12 K 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 13. Absorp.Area 4. Loading Rate S. Perc. Rate 6. System Elev. 7. Final Grade <br /> Required ed(sq.ft.) Proposed(sq.ft.) (Gals/day/sq.ft.) (Min./inch) n6 e E vation <br /> 45P 'I 3 �- "� Feet 3 Feet <br /> VII. TANK Capacity Site <br /> in gallons Total #of Manufacturer's Name Prefab. Con- Steel Fiber- Plastic Exper. <br /> INFORMATION New Existin Gallons Tanks concrete strutted glass App. <br /> Tanks Tanks r� <br /> Septic Tank or Holding Tank 0 ❑ <br /> Lift Pump Tank/Siphon Chamber ❑ ❑ 1 <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:(PrI t) Plumber' Signature:(N S amps) MP/MPRSW No.: Business Phone Number: <br /> I11vW0 aDFm/ — I =.<85 l5- S <br /> Plumber's Address(Street,City,Ittte,Zip Code): <br /> O �. <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> El Disapproved Sanitar Per 't Fe llndudesGroundwater ate ssue Issuing Ag t gnat r ) <br /> roved arge Fee) <br /> .App ❑Owner Given Initial � • <br /> Adverse Determination <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398 IRA 1/97) DISTRIBUTION: Original to County.One copy To: Safety 8 Buildings Division,Owner,plumber <br />