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Safety and Buildings Division <br /> An nsin SANITARY PERMIT APPLICATION 201 W.Washington Avenue <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 � '7b, <br /> than 81/2 x 11 inches in size. <br /> • See reverse side for instructions for completing this application State Sanitary Permit Number <br /> � 534 <br /> Personal information you provide may be used for secondary purposes ❑Check wsioto to previous application <br /> [Privacy Law,s. 15.04(1)(m)]. State Plan I.D.Number <br /> 1. APPLICATION INFORMATION - PLEASE PRINT ALL INF RMATION I ^ <br /> PropeLtlOwner Name Property Location '�'�-�� <br /> 1�1JE 01J ��].-" G4IaW4;S 12 T '41 N, R IS E(or(" ) <br /> Property Owner's Mailing Address Lot N tuber Block Number <br /> Et7 bJaDfl lQ Ia+ 18+ <br /> 19 <br /> City,State Zip Code Phone Number Subdivision Name or M Number <br /> tmt4oi sso 14 1( (*rZ)_/%.qZDIIp- I - <br /> F BUILDING: (check one) ❑ State Owned [] 01ty Nearest Road <br /> p Village <br /> Public 1 or 2 FamilyDwelling-No.of bedrooms OF 5 Town (_<r JV. LK. eQD. <br /> III. BUILDING USE: (If building type is public,check all that apply) Parcel Tax Number(s) <br /> 1 ❑ Apartment/Condo 0-39, <br /> ,2' /a, —7 <br /> O0 <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.,XReplacement 3. ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an <br /> _Sytstem ........System------------- TankOnly_____________ 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 /> 11Seepage Bed 21 ❑Mound 30❑Specify Type 41 []Holding Tank <br /> 12Seepage 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/d y/sq.ft.) (Min./inch) E evation <br /> 73 Z . I /�� !p. 3 Feet $- Feet <br /> IANK Ca aclt <br /> VII. FORMATION in gallons Total #of Manufacturer's Name Prefab. Con- Steel Fiber- plastic App. <br /> New Existin Gallons Tanks Concrete structed glass App. <br /> T nks I Tanks <br /> Septic Tank or Holding Tank 170 —" �Q xAQ ® ❑ ❑ ❑ 1 ❑ ❑ <br /> Lift Pump Tank/Siphon Chamber ❑ ❑ ❑ ❑ ❑ ❑ <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:(No mps) MP/MPRSW No.: Business Phone Number: <br /> 1414aQc> 4clrglffs I 342 115-5 6. 41-57 <br /> PI tuber's Address(Street,Cit ,State,Zip Code): <br /> 2-"l'( w is w6soolm Wl. 3 <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑Disapproved Sanitary Permit Fee (Includes Groundwater P13A <br /> Issued Issuing Agent Si ature o Sgm <br /> VAproved ur harge Fee) <br /> P p ❑Owner Given Initial od Adverse Determination <br /> X. CONDITIONS OF APPROVAL/REASONS FO ISAPPROVAL: <br /> SBD-6398(R.11/97) DISTRIBUTION: Original to County.One copy To: Safety&Buildings Division.Owner,Plumber <br />