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Safety and Buildings Division <br /> AsiiionsfnSANITARY PERMIT APPLICATION 201 E.Washington Ave. <br /> In accord with ILHR 83.05,Wis.Adm.Code P.O.Box 7969 <br /> Department of Commerce Madison M 53707 7968 <br /> • Attach complete plans(to the county copy only)for the system,on paper not less County <br /> than 8112 x 11 inches in size. /� J <br /> • See reverse side for instructions for completing this application State Sanitary Permit Number <br /> The information you provide may be used by other government agency programs 3 3 on o 0 <br /> Check <br /> [Privacy Law,s. 15.04(1)(m)I. ❑ if revision b pr application <br /> State Plan J.D.Number <br /> I. APPLICATION INFORMATION- PLEASE PRINT ALL III MATION I -- <br /> Property Owner NameProperty Location <br /> // d/e /:1 114 114,S ,�7 T .38r,N,R /y E(orxwl <br /> Property Owner's Mailing Address Lot Number Block Number <br /> ter' St , -- <br /> city,state Zip Code I Phone Number Subdivision Name or CSM Number <br /> L/0-71'4 M^) 93V (500 9 - Vviq <br /> BUILDING:Il. TYPE OF (check one) ❑ State Owned ❑ tt� Nearest Road <br /> vil <br /> Public 1 or 2 FamilyDwellingTo <br /> -No.of bedrooms age z o •A-/-J <br /> Town OF a lt-�2. <br /> Ill. BUILDING USE: (If building type Is public,check all that apply) Parcel Tax Number(s) <br /> 1 ❑ Apartment/Condo I 1 0d9 — -2 - - - v -7 <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. D4 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 0j 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 /> J O v <br /> Ay C;.9 q5 Z - Feet ?do 4:� Feet <br /> VII. TANK Capacity <br /> INFORMATION in gallons Total #of Manufacturer's Name Prefab. Site Fiber- Exper <br /> New Existin Gallons Tanks Concrete CO"' Steel glass Plastic App <br /> Tanks Tank, strutted <br /> Septic Tank or Holding Tank SO 'SH 0 00 1 I] ❑ <br /> 11h Pump Tank/Siphon Chamber <br /> 15'6io 00 ® ❑ El 1 11 ❑ <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:(No Stamps) MPIMMPRSW/No.: Business Phone Number: <br /> ILJ C/A /C /--�-:art/. /.� .�.r' /��/ J �vP 3Y 9. 7 9 �6 <br /> Plum er's Ac dress(Street,City,State,Zip Code): <br /> IX. COUNTY if DEPARTMENT USE ONLY <br /> ❑Disapproved Sanitary Permit Fee (Incluc Groundwate ate Issued, Issuing Agent Signature(No Stamps) <br /> ,Approved ❑Owner Given Initial _ / Surcharge Fee)) <br /> c / <br /> Adverse Determination 117- <br /> S, C <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(R.11%) DISTRIBUTION: Original to County.One copy To: Safety a Buildings Division.Owner,Plumber <br />