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C37'L Z.c'1Y� <br /> Safety and Buildings Division <br /> V6onsin 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 <br /> than 8 12 x 11 inches in size. <br /> • See reverse side for instructions for completing this application State Sanitar Permit(�/Nuumber ) <br /> Personal information you provide may be used for secondary purposes ❑Check it r3gp_r-, io pplication l' <br /> [Privacy Law,s. 15.04(1)(m)]. <br /> State Plan I.D.Number <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INF RMATI N <br /> Propertywner Name Property Location <br /> O 1/4 1/4,5 1Z T dT6 ,N, R E(or(ora <br /> Property wner' Mailing Address Lot Nu ber <br /> 'J z- <br /> CitState Zip Code Phone Number Subdivi ion Name or CSM Number <br /> W <br /> W l SA(el ( > -4 z -2D8 <br /> II. TYPE OF BUILDING: (check one) ❑ State Owned 0 Lity Nearest Road <br /> Public 1 or 2 Family Dwelling-No.of bedrooms 'z E] Villae TOw9 OF SC_o M)(2R . / K <br /> 111. BUILDING USE: (If building type is public,check all that apply) Parcel TaxNumber(s) <br /> 1 ❑ Apartment/Condo oz— 4112 02 94 <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----------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 ❑Seepage Bed 21 ❑Mound 30❑Specify Type 41 ❑Holding Tank <br /> 12eepage Trench 22❑In-Ground Pressure 42❑Pit Privy <br /> 13❑ eepage Pit 43❑Vault Privy <br /> 14❑System-In-Fill <br /> VI. ABSORPTION SYSTEM INFORMATION: _ q7.55- <br /> 1. Gallons Per Day 2- Absorp.Area 3. Absorp.Area 4. Loading Rate 5. Perc. Rate 6. System EJev. 7. Final Grade <br /> Required(sq.ft.) Proposed(sq.ft.) (Gals/day/sq.ft.) (Min./inch) 9!;,o57 b,/ Elevation <br /> 4!5 ' 5—In/ S E Feet E-2 7.* ,SFeet <br /> TANK Capacit VII. INFORMATION in allons Total #of Manufacturer's Name Prefab. con steel Fiber- Exper <br /> New Exist ng Gallons Tanks Concrete glass Plastic App <br /> Tanks Tanks strutted <br /> Septic Tank or Holding Tank 10 1 n 1:1 E <br /> Lift Pump Tank/Siphon Chamber, [I [j Ej 11 13 <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:( o S ps) MP/MPRSW No.: Business Phone Number: <br /> � 49 o - Zz sibs 5- �(a6- <br /> P mber's Address(Street,CitState,Zip Code): <br /> T-11 Inr I , 3 <br /> IX. COUNTY I DEPART ENT USE ONLY <br /> ❑Disapproved Sanitai rmitF des Groundwater ate issuedIssuing ge Signature(N ps) <br /> 9 pproved ❑Owner Given Initial f�J arge Fee) <br /> Adverse Determination I / /_1 4� <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 />