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6nCff7n_10"' <br /> Safety and Buildings Division <br /> SANITARY PERMIT APPLICATION 201 W.Washington Avenue <br /> Visconsin 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 County 3g�Q <br /> than 8 vi x 11 inches in size. u�/t O <br /> • See reverse side for instructions for completing this application State San'ittaary Permit Nuumm/beerr <br /> Personal information you provide may be used for secondary purposes C]Check tt4ev ion to3 viou4 application <br /> [Privacy Law,s. 15.04(1)(m)]. State Plan I.D.Number <br /> I. APPLICATION INFORMATION-PLEASE PRINT ALL INF RMATION <br /> Property Owner Name Property Location <br /> 6.9 f2 aL4 &"U CtM 1/4 1/4,S T Y& ,N,R`4 E(or W <br /> Property Own r'sMailingAddress _ Lot Number Block Number <br /> v 7,7, m z k4ovp 9-1, a- <br /> -City,State Zip Code f Phone Number Subdivision Name or CSM Numb r <br /> lv6o/Itri n9� 5 l� �'� CM-) 7 99S q 'S e-_ �A4111W <br /> 11. TYPE OF BUILDING: (check one) ❑ State OwnedLJ ltr Nearest Road <br /> Public 1 or 2 FamilyDwelling-No.of bedrooms _ own of �� � �C <br /> III. BUILDING USE: (If building type is public,check all that apply) Parcel TaxNumber(s) <br /> aft - III 300- 65)--1 77e tfeD <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. New 2. [:] Replacement 3. E] Replacementof 4_ E] Reconnection of 5_ ❑ Repair of an <br /> _ __�rstem __ _ SY;tem TSystem <br /> ank Only - __ __ Existing System ____-_--_Exlstlnc�----- <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 ❑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 /> Req j(sq.ftJ 1 4010<1119 ProProposed(sq.ft.) (Gala/sq.ft.) (Min./inch) Elevation <br /> �SO <br /> c f7--l'6' Feet 95Z"e Feet <br /> VII. TANK Capacity site <br /> in gallons Total #of Manufacturer's Name Prefab. Con- Steel Fiber- plastic Exper <br /> INFORMATION New Existin Gallons Tanks Concrete glass App. <br /> strutted <br /> Tanks Tanks <br /> Septic Tank or Holding Tank led D <br /> Lift Pump Tank/Siphon Chamber El ❑ <br /> VIII. RESPONSIBILITY STATEMENT <br /> I,the undersigned,assume responsibility for installation of the onsite sewage system shown on the attached plans. <br /> Plum�er's Name:(Print) <br /> Plum Signature:(No S s)- MP/MPRSW No.: Business Phone Number: <br /> 110�►-f`0� L=-Trc��7' �_ ou�7® ��� off- 3So � <br /> Plumber's Address(Street,City,State,Zip Code): <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑Disapproved S itary Permit Fee (Includes le Fee)waterT;a7te-r;sS`7e Issuing Agent Signature(No St ps) <br /> surchargeFee) SLIZproved ❑Owner Given Initial (o- GTS <br /> Adverse Determination <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(R.11/97) DISTRIBUTION: Original to County,One copy To: Safety&Buildings Division,Owner,Plumber <br />