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X72 Ck <br /> SANITARY PERMIT APPLICATION safety and Buildings Division <br /> 14sconsin 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 Count <br /> than 8 1/2 x 11 inches in size. li y rim, � c�!S <br /> • See reverse side for instructions for completing this application State San Permit t NNuum(berr <br /> Personal information you provide may be used for secondary purposes ❑Check it re, , vious ap tion ( , <br /> IPrivacy Law,s. 15.04(1)(m)]. State Plan I.D.Number YJ <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INF RMATI N <br /> Property Owner Name Property Location <br /> �a. AjLd/4 SF 1/4,5 T �O ,N, R f i4WI0 <br /> PropertyOwner's ailing Address Lot Number 5 Block Number <br /> 4, O <br /> City,State Zip CodePhone Number Subdivision Name or CSM umber <br /> A;I 111,11h (�I�>79(a'S S ov Lot + N (e ba 0aete-S <br /> 11. TYPE OF BUILDING: (check one) ❑ State Owned City❑ c N arest Road <br /> Village J(✓ 44- e S le r . <br /> Public 1 or 2 FamilyDwelling-No.of bedrooms ❑ Town OF <br /> III. BUILDING USE: (If building type is public,check all that apply) Parcel TaxNumber(s) <br /> 1 ❑ Apartment/Condo d - c3 - l <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. phew 2. ❑ Replacement 3. ❑ Replacement of 4_ ❑ Reconnection of 5. ❑ Repair of an <br /> System System <br /> -___ _ ---_-- _ Tank Only _ ExistingSystem __ --_ 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 ERSeepage 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 /> 3o e yz y3 ZqZ o Feet � 3 <br /> Feet <br /> Ca aut <br /> VII. Site <br /> FORMATION in gallons Total #of Manufacturer's Name Prefab. Con- steel Fiber- Plastic Exper. <br /> New Existin Gallons Tanks Concrete strutted glass App. <br /> Tanks Tank <br /> ptic Ta or Holding Tank ® ❑ ❑ ❑ ❑ ❑ <br /> Lift PumpTank/Siphon Chamber ❑ ❑ ❑ ❑ ❑ ❑ <br /> VIII. RESPONSIBILITY STATEMENT <br /> I,the undersigned,assume responsi lity for installation of the onsite sewage system shown on the attached plans. <br /> Plumber's Name:(Print) PI mber's Signat re: o Stamps) MP/MPRSW No.: Business Phone Number: <br /> w Lf 'dr <br /> umberG's Address(Street,Cit ,Stat ,Zip Code): f <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑Disapproved Sanitary Permit Fe (Includes Groundwater ate Issue Issuing Ag n ignaturM(Ns) <br /> d roved Okguprge ee) <br /> pp ❑Owner Given Initial l 7����Z� <br /> Adverse Determination < <br /> X. CONDITIONS OF APPROVAL/REASONS FOR SAPPROVAL: <br /> SBD-6398(R.11/97) DISTRIBUTION: Original to County.One copy To: Safety&Buildings Division,Owner,plumber <br />