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Safety and Buildings Division <br /> %SCOI15%I1 SANITARY PERMIT APPLICATION Po Bo 7969 <br /> Department <br /> De artment of Commerce In accord with[LHR 83.0 5,Wis.Adm.Code <br /> P Madison,WI 53707-7969 <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. �u �e /7�. <br /> • See reverse side for instructions for completing this application State Sanitary Permit Number <br /> � 6/.57 <br /> The information you provide may be used by other government agency programs p Check it revision to previous application <br /> [Privacy Law,s. 15.04(1)(m)]. <br /> State Plan LD.Num e <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION <br /> Property finer Name Property�Location <br /> e e e- e(� va / (e) 1/4,S T ,N, R//7 E(or)(& <br /> Property Owner's Mailing Address Lot Number Block Number <br /> City,StateZip Code Phone Number Subdivision Name or CSM NumberCkz <br /> 5 7�e Gni S e7. ( )3Y9=.27Sa c� <br /> IL TYPE OF BUILDING: (check one) ❑ State Owned ❑ it� / Nearest Road / <br /> Public 1 or 2 FamilyDwelling-No.of bedrooms Vown OF �Awf - . 5' ,q 6e,- <br /> III. BUILDINGUSE: (If building type is public,check all that apply) Parcel Tax//Number(s) c/ / <br /> 1 E] Apartment/Condo D D 6 _" 01;?!� — O l-- 164 b D <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. Jam-' 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 /> 12❑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 3. Perc. Rate 6. System Elev. 7. Final Grade <br /> �O Required (sq.ft.) Proposed(sq.ft.) (Gals/day/sq.ft.) (Min./inch) S Elevation <br /> p0 �� Feet .5"r Feet <br /> Ca act Site <br /> VII. INFORMATION in gallons Total #of Manufacturer' Prefab Con- steel Fiber- Plastic Exper <br /> New Existin Gallons Tanks Concretes Name glass App <br /> Tanks Tanks / strutted <br /> Septic Tank or Holding Tank ❑ ❑ ❑ ❑ ❑ <br /> Lift Pump Tank/Siphon Chamber ❑ ❑ ❑ I ❑ I ❑ ❑ <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 Stamps) MP/MPRSwNo-: RusinessPhone Number: <br /> A.g�,e_ k 4114�,4a �c1c7,3-PG <br /> Plumber's Ar dress(Street,City,State,Zip Code): <br /> ,QGX _575" <br /> IX. COUNTY/DEPARTMENT LISVE ONLY <br /> ❑Disapproved Sanitary Permit Fee (includes Groundwater ate Issued Issuing Agent Sig ature o5t <br /> proved ❑Owner Given Initial l�gur<hargeree) <br /> u Adverse Determination �� 6eG �3 / <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(R.11198) DISTRIBUTION: Original to County.One copy To: Safety B Buildings Division,Owner,Plumber <br />