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J <br /> Safety and Buildings Div sion <br /> SANITARY PERMIT APPLICATION 201 W.Washington Avenue <br /> Visconsin P O Box 7302 <br /> Deportment of Commerce In accord with Comm 83.05,Wis.Adm.Code Madison,WI 53707-7302 9j <br /> • Attach complete plans(to the county copy only)for the system,on paper not less County a _ (�, <br /> than 8 1/2 x 11 inches in size. 1' <br /> • See reverse side for instructions for completing this application State Sanitary Permit Numb r V� <br /> Personal information you provide may be used for secondary purposes ❑Check'T revi--U t previous pplication <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 Owner Name Propert Location <br /> c Ul e h n So rl A/&7i4 A W114,S 10 T 3 q ,N, RE(or) <br /> Property Own is Mailing Address Lot Number Block Number <br /> 3w 1 t1, st. /v6,. " 3 <br /> City,State + Zip a(a(9 Phone Number Subdivision Name or CSM Number <br /> ww orin � 6-07)45/—o 766 <br /> II. P BUILDING: (check one) ❑ State Owned it( Nearest Road <br /> ❑ VII age <br /> Public 1 or 2 FamilyDwelling-No.of bedrooms iL Town OF IRS�C 6c Rd G <br /> III. BUILDING USE: (If building type is public,check all that apply) Parcel TaxNumber(s) <br /> 0,;k 4 -3110 -01 - BOO <br /> 1 ❑ Apartment/Condo <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. g New 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an <br /> System System Tank Only--__-__ __ Existing system----------- Existing System <br /> ------ ----------------------------------- <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 J@ 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 /> Re fired(sq.ft.) Proposed(sq.ft.) (Gals/day/sq.ft.) (Min./inch) Elevation <br /> 30Q p1 /, ^. q7-$ Feet Feet <br /> VII. TANK Capacity Site <br /> in gallons Total #of Manufacturer's Name Prefab. Con_ Steel Fiber- plastic App. <br /> INFORMATION New Existin Gallons Tanks Concrete strutted Blass App <br /> Tanks Tanks <br /> Septic Tank or Holding Tank �y <br /> Lift Pump Tank/Siphon Chamber /Iq 0 ri <br /> VIII. RESPONSIBILITY STATEMENT <br /> ],the undersigned,assume responsibility for installation of the onsite sewage system shown on the attached plans. <br /> PI ber's Name:(Print) Plumber's Signature:(No St ps) MP/MPRSW NO.: Business Phone Number: <br /> iflXxo ,Js ?2 r8s� 5- 236646 <br /> Plumber's Address(StreCity,State,Zip Co e :760 <br /> IX. OU TY/ DEPARTMENT USE ONLY <br /> ❑Disapproved Sanitary Permit Fee (includes Groundwater ate ssue Issuing A nt Signature(No Stamps) <br /> Surcharge Fee) 0 <br /> pproved ❑Owner Given Initial Roo 00 — I m L <br /> Adverse Determination <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6396(R.4199) DISTRIBUTION: Original to County.One copy To: Safety&Buildings Division,Owner,Plumber <br />