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�fety and Buildings Division <br /> ` 5CO11SII1 SANITARY PERMIT APPLICATIONS 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 ,/ �� <br /> than 8 vi x 11 inches in size. L4Ri, <br /> • See reverse side for instructions for completing this application State Sanitary Permi <br /> itt Number <br /> Num <br /> Personal information you provide may be used for secondary purposes ❑Check if re-F3y/ <br /> pr'evi ws as application <br /> IPrivacy Law,s. 15.04(1)(m)]. State Plan I.D.Number <br /> LAPPLICATION INFORMATION- PLEASE PRINT ALL INF RMATI N <br /> Prop rt Owner Name Property Location <br /> K Ve U 1/4 1/4,S It T 4p ,N, R JAr E(or W <br /> Propert Owner's Mailing Address Lot Number WeckAluaBl�er <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> L I\J -7 ( 12) 2 <br /> II. Y F BUILDING: (check one) ❑ State Owned it(r RfLi-_ff <br /> rest Road <br /> ❑ VII age <br /> Public 1 or 2 FamilyDwelling-No.of bedrooms 3 Town OF SCoTr b cx <br /> Parcel Tax Number(s) 7< �6 <br /> III. BUILDING USE: (If building type is public,check all that apply) sl �I <br /> 1 ❑ Apartment/Condo y <br /> 2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Outdoor Recreat c'rfity <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. N Replacement 3, ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an <br /> _-System - _System _ Tank Only ____________ Existing System ________ E----tinq 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 W Seepage Bed 21 ❑Mound 30❑Specify Type 41 ❑Holding Tank <br /> 12 tj Seepage Trench 22❑In-Ground Pressure 42❑Pit Privy <br /> 13❑Seepage Pit 43❑Vault Privy <br /> 14❑System-I n-Fi l l <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 /> Re uuirred(sq.ft.) Pro o�d(sq.ft.) (Gals/day/sq.ft.) (Min./inch) Elevation <br /> ��•O Feet Q$•S Feet <br /> VII. TANK Capacity site <br /> INFORMATION in gallons Gallons Tanks Manufacturer's Name Cone Prefab. Con- Steel Fiber-ass Plastic Appr. <br /> New Existin structed <br /> Tanks Tanks <br /> Septic Tank or Holding Tank gl A�J ® ❑ ❑ El ❑ <br /> Lift Pump Tank/Siphon Chamber ❑ El 1-1 0 <br /> VIII. RESPONSIBILITY STATEMENT <br /> I,the undersigned,assume responsibility for installation of the onsite sewage system shown on the attached plans. <br /> Plumbers Name:(Print) Plumber's Signature:(No raps) MP/MPR5W No.: Business Phone Number: <br /> ,cf4AR0 Oopl<ms 3�26 lS- 866- 4137 <br /> P mber'sAddress(Street,City State,Zip Code): <br /> 2-7-760 Awv 3-< �tJ613 5T Z59 W1, .54-5 q 3 <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑Dlsa roved Sanitary Permit Fee (Includes Groundwater at7lss;/e Issuin A ntsign t o amps) <br /> pp1��� Surcharge Fee) � S00, <br /> Approved ❑Owner Given Initial <br /> Adverse Determination <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> .SBD-6398(R.11/97) DISTRIBUTION: Original to County.One copy To: Safety&Buildings Division,Owner,Plumber <br />