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Safety and Buildings Division <br /> F! SANITARY PERMIT APPLICATION Bureau of Building Water Systems <br /> 201 E.Washington Ave. <br /> In accord with ILHR 83.05,Wis.Adm Code P O-Box 7969 <br /> Madison,WI 53707-7969 <br /> • Attach complete plans(to the county copy only)for the system,on paper not less Count A <br /> than 8 yr x 11 inches in size. <br /> • See reverse side for instructions for completing this application State Sanitary Per it Numb r <br /> 3lT <br /> The information you provide may be used by other government agency programs ❑Check it revision to previous application <br /> (Privacy Law,s. 15.04(1)(m)). State Plan I.D.Number,. /^ <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION NPJJ}— <br /> Property Owner Name Property Location <br /> G/SA 4,99rI �t/4 . t/4,S (3 T 3^y N, R i f �W <br /> 001 <br /> Property Owner's Mailing Address LotN rb <br /> E 20,4b Block Number <br /> City,State Zip Code Phone Number Su division Name or CSM Number <br /> 44 /oma 9 acres <br /> Nearest Road <br /> II. TYPE F BUILDING: (check one) ❑ State Owned ❑ City <br /> E] Village <br /> Public 1 or 2 Family Dwelling- No.of bedrooms _ IeTown OF SKK <br /> 111. BUILDING USE: (If building type is public,check all that apply) Parcel TaxNumber(s) <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..W 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;4 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 /> _Ab 3 6 8 . 7 ®Jfai d/3 c Feet i449'7aeet <br /> Ca act Fib Site <br /> VII. FORMATION in gallons Galltons Tanks Manufacturer's Name co�c efe Con- Steel g ass Plastic APPr. <br /> er <br /> New Existin strutted <br /> Tanks Tanks <br /> Septic Tank o&1W44PmTfwrrIc4 /oOp oO0 / 49 <br /> ❑ ❑ ❑ ❑ ❑ <br /> Lift Pump Tank/Siphon Chamber ❑ ❑ ❑ ❑ I ❑ ❑ <br /> VIII. RESPONSIBILITY STATEMENT <br /> I,the undersigned, responsibility for installatio f the onsite sewage system shown on the attached plans. <br /> Plumber's NaSEPM & EXCAVATI�j4n!jsaturei( tamps) yp/MPRSW No.: Business Phone Number: <br /> N8228 Coun Line R lX a�871 <br /> Plumber's Address(S , &Wode): <br /> (715)635-7482 <br /> IX. COUNTY/ DEPARTMENT USE ONLY <br /> ❑Disapproved Sanitary Permit Fee 0n`ludes Groundwater ate Issue Issui ent Signature(No Stamps) <br /> roved Surcnargeree) / I� /f <br /> 'App ❑Owner Given Initial � (rc' / g <br /> vv Adverse Determination eor <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SI11)-6398(R.05/94) DISTRIBUTION. Original to Could,One urpl,To: S„IOV 8 Buildings Divs ion.Owner,Plumber <br />