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C <br /> Safety and Buildings <br /> VisconsinSANITARY PERMIT APPLICATION 201 W.WashingtonAvel,. <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 County <br /> than 8 112 x 11 inches in size. NK <br /> • See reverse side for instructions for completing this application State Sanitary Per it Number, 7S <br /> Personal information you provide may be used for secondary purposes ❑Check if revision to p evlous ap�plicat'ion SW <br /> SW <br /> [Privacy Law,s. 15.04(1)(m)]. State Plan I.D.Number <br /> J. APPLICATION INFORMATION - PLEASE PRINT ALL INF RMATI N <br /> Property Owner Name Property Location <br /> v 1/4 1/4,S Z3 T ,N, R is E(orG <br /> Property Owner's Malin Address Lot Number Block Number <br /> 2 S1- 52 <br /> City tate I Zip Code Phone Number Subdivision Name or CSM Number <br /> �` AG11JAlr./ 1J- ( 218> -491 010`69 Qq MD Afl0 TO V.V <br /> 11. E OF BUILDING: (check one) ❑ State Owned o v ilage Nearest Road <br /> Public 1 or 2 Famil Dwellin -No.of bedrooms Town OF TAC KSO4 04MANID TQ- WA <br /> Ili. BUILDING USE: (If building type is public,check all that apply) Parcel Tax Number(s) <br /> 1 ❑ Apartment/Condo r( <br /> orz 15oo CG 100 <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. ew, 2. E] Replacement 3_ E] Replacement of 4. E) Reconnection of 5. C] Repair of an <br /> System _ _ _System Tank OnlyExisting 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 Meepage Bed 21 ❑Mound 30❑Specify Type 41 ❑Holding Tank <br /> 1 Zn 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 /> 30o Required sq.ft.) Proposed(sq.ft.) (Gals/day/sq.ft.) (Min./inch) C� E evat] n <br /> �� 1- - , 1_. 15 $ Feet Feet <br /> Capaut <br /> VII INFORMATION in allons Total #of Manufacturer's Name Prefab. Con-Site Steel Fiber- Exper- <br /> Gallons Tanks Concrete glass Plastic App <br /> New Existin structed <br /> Tank Tank <br /> Septic Tank or Holding Tank O 1 x{I11J ❑ ❑ ❑ 1 ❑ ❑ <br /> Lift Pump Tank/Siphon Chamber ❑ ❑ 111 ❑ 1 ❑ ❑ <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) Plumber's Signature:(N St ps) MP/MPRSW No.: Business Phone Number: <br /> �IfRRD PK�nIS u � 'LzSIs 5_ $66- S <br /> PI tuber's Address( treet,Cit ,State,Zip Code): �`���n �' 51481932>- „„ <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑Disapproved Sanitary Permit Fe (Includes Groundwater ate issuedIssuin Ag t Signat re( S ps) <br /> proved [-]Owner Given Initial /�� S rchargefee) —17 4 <br /> Adverse Determination ( lGN 7( <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(8,11/97) DISTRIBUTION: Original to County,One copy To: Safety&Buildings Division,Owner,Plumber <br />