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Cry: <br /> SANITARY PERMIT APPLICATION Safety and Buildings Division <br /> 201 E.Washington Ave. <br /> `4sconsin <br /> In accord with[LHR 83.05,Wis.Adm.Code P.O.Box <br /> Department of Commerce Madison,W1 WI 53707-7969 <br /> • Attach complete plans(to the county copy only)for the system,on paper not less County a (� <br /> than 8112 x 11 inches in size. 61A r 11 <br /> • See reverse side for instructions for completing this application State Sanitary Permit Number <br /> The information you provide may be used b other government agency programs `� �� ` � Q t <br /> Y P Y Y 9 9 Y P 9 ❑Check i revision o previous application +v <br /> [Privacy Law,s. 15.04(1)(m)). <br /> State Plan I.D.Number 11, <br /> 1. APPLICATION INFORMATION - PLEASE PRINT ALL INF RMATION — Kl <br /> Property Owner Name Property Location <br /> [� 1/4 1/4,S /4 T 40 ,N, RIS E(or)® <br /> Property Owner's Mailing Address Lot Number Block Number <br /> L0705` AV, //� / <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> ou MA/, s k (�I�)s` -187 s u <br /> ( . PE F BUILDING: (check one) ❑ State Owned itNearest R <br /> Public 1 or 2 FamilyDwellingVil?-No.of bedrooms 0 Town of d/L fPd� `V Y' <br /> III. BUILDING USE: (If building type is public,check all that apply) Parcel Tax Number(s) <br /> 1 ❑ Apartment/Condo 1 O I X _q(0`2L—o �oU <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/Mote[ 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. E,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 /> 1 1,RSeepage 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.) Proposesq.ft.) (Gals/day/sq.ft.) (Min./inch) Elevation <br /> Feet C14 1 7 Feet <br /> city VII. TANK in Cap <br /> Total #OfPrefab Site Fiber- plastic Exper <br /> INFORMATION New Existin Gallons Tanks Manufacturer's Name Concrete Con- Steel glass App <br /> Tanks Tanks �+ strutted <br /> Septic Tank or Holding Tank O QQ I' s,[+�¢W ® ❑ ❑ ❑ ❑ ❑ <br /> Lift Pump Tank/Siphon Chamber ❑ ❑ ❑ ❑ ❑ ❑ <br /> VIII. RESPONSIBILITY STATEMENT <br /> 1,the undersigned,assume responsibility for installation of the onsite sewage system shown on the attached plans. <br /> Plumber's Name:(Print) Plumber'sSignature (No amps) - MP/MPRSW No.: Business Phone Numb r: <br /> 1 c R.r� o XJ7,15 wL�l 1 Z2S851 <br /> Plum ber's Ac dress(Street,Cit ,State,Zip Code)J��J1 54-M <br /> Q-7-7 U W 'c-r�Q <br /> IX. COUNTY/DEPARTM ENT USE ONLY <br /> ❑Disapproved SamaryPermi a Ig_hudesOroundwater at Issuing g Sig ture( ps) <br /> roved ha eFee) <br /> I* I pp ❑Owner Given Initial K_�5�11? <br /> Adverse Determination <br /> X. CONDITIONS OF APPROVAL/REASONS FOR ISAPPROVAL: <br /> S6D-8388(R.11/96) DISTRIBUTION: Original to County,One copy To: Safety 8 Buildings Division,Owner,plumber <br />