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Safety and Buildings Division <br /> SANITARY PERMIT APPLICATION 201 E.Washington Ave. <br /> NALConsin In accord with ILHR 83.05,Wis.Adm.Code P.O.Box 7969 <br /> DMadison,WI 53707.7969 <br /> Department of Commerce <br /> • Attach complete plans(to the county copy only)for the system,on paper not less County a��03 `� <br /> than 8 1/2 x 11 inches in size. <br /> S ate Sanitary Permit Number <br /> • See reverse side for instructions for completing this application 33J q/-S <br /> 1CJ 1CJ <br /> The information you provide may be used by other government agency programs ❑Check if revision to previous application <br /> [Privacy Law,s. 15.04(1)(m)]. State Plan I.D.Number <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INF RMATI N <br /> Property caner Name P/opert Location <br /> ISI ENZ _ 0ylt/a AW t/a,S 5 T 40 ,N, R 14 E(or W <br /> Property Owner's Mailing Address Lot Number Bloek+ftrmber <br /> 1541 R"EL WAY <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> 55124 ((am 031 40L• (V <br /> II. TYPE OF B LDIN : (check one) ❑ State Owned ❑ Lity Nearest Road <br /> Village /J{Sy7 F. LD1 r. LX RD, <br /> Public 1 or 2 FamilyDwelling-No.of bedrooms 2 Town OF car r s <br /> III• BUILDING USE: (If building type is public,check all that apply) Parcel TaxNumber(s) <br /> 1 ❑ Apartment/Condo 1 0211-405-02- 1 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.,M New 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an <br /> System System _ Tank Only ........ Existing System __ _____Existing System <br /> B) E] 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 5. Perc. Rate 6. System Elev. 7. Final Grade <br /> Required(sq.ft.) Proposed(sq.ft.) (Gals/day/sq.ft.) (Min./inch) Elevation <br /> �jao I 432- ��] �—� q.3.Ito Feet95- 7 Feet <br /> Ca actt Prefab Site <br /> VII INFORMATION in gallons Gallons Tanks Manufacturer's Name Concrete Con- Steel Fiber-ass Plastic APpr. <br /> New Existingstrutted <br /> Tanks Tanks I-L+Septic Tank or Holding Tank Six I � 13001300J A+^r 0 ElE El R <br /> Lift Pump Tank/Siphon Chamber I I I 1 1:1 1 1 <br /> Vlll. 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:( Stamps) MP/MPRSW No.: Business Number: <br /> 1144 ZD P ' nIS .27Z596I115- :866- 415-7 <br /> Pumbre�r'sArdress(Str et,City, <br /> �State,ZipCod 1} ` �Qq' <br /> L17(ion _ alaww W U <br /> IX. COUNTY/ DEPARTMENT USE ONLY <br /> ❑Disapproved Sanitary--- <br /> "111P Permit <br /> Fee (in`lude%Groundwater ate sue Issuing Ag ignature o St p <br /> �Surchar Fee) <br /> pproved ❑Owner Given Initial <br /> Adverse Determination <br /> X. CONDITIONS OF APPROVAL/REASONS OR DISAPPROVAL: <br /> SBD-6398(R.11/96) DISTRIBUTION: Original to County.One copy To: Safety 8 Buildings Division,Owner,Plumber <br />