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P Safety and Buildings Division <br /> is=iii: SANITARY PERMIT APPLICATION Bureau of Building Water Systems <br /> sur E.was <br /> In accord with ILHR 83 05,Wis.Adm.Code P.O 89 69 <br /> Ma (son,WI 53707-7969 <br /> • Attach complete plans(to the county copy only)for the system,on paper not less County /I / <br /> than 8112 x 11 inches in size. el e- 7 (® <br /> • See reverse side for instructions for completing this application State Sanitary Permit Nu <br /> ;Z5ZI/On <br /> The information you provide may be used by other government agency programs E]Check it revision to previous application <br /> [Privacy Law,s. 15.04(1)(m)l. <br /> State Plan I .Number <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION ^— <br /> Pro erty Owner Name Property Lo ation <br /> oN e_ /S 0/t) tj 1/4 s 1/4,S T 3� ,N, R /5 E(or) <br /> Property Owner's Mailing Ad s Lot Number Block Number <br /> "100.9/ - - 70 <br /> City,State Zip Code Phone Number 5 tie - '^^or CSM Number <br /> 5494S ( )3 -,2 37 / <br /> II. TYPE OF BUILDING: (check one) ❑ State Owned ❑ ct�, Nearest Road -2 y <br /> ❑ VII age <br /> Public 1 or 2 Family Dwelling- No.of bedrooms Town oFLA o <br /> SII. BUILDING USE: (If building type is public,check all that apply) Parcel Tax Number(s) <br /> 1 ❑ Apartment/Condo 0 — -7 t' 3 �� 3 <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 1 ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an <br /> System System Tank Only Existing System Existing System <br /> -------------------------------------------------------------- <br /> --------------------- <br /> ------------ <br /> B) ❑ A Sanitary Permit was previously issued. Permit Number Date Issued <br /> V. TYPE OF SYSTEM: (Check only one) <br /> NonPressurizedDistribution 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 S. Perc. Rate 6. System Elev. 7. Final Grade <br /> Required (sq. ft.) Proposed(sq.ft.) (Gals/day/sq. ft.) (Min./inch) Elevation <br /> 0© 6 t//� �;, 9e.Y Feet Feet <br /> Ca acct <br /> VII. TANK in allons Total #of Prefab Site Fiber- Exper <br /> INFORMATION g Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App <br /> New Existin strutted <br /> Tanks Tanks <br /> Septic Tank or Holding Tank 75--0 Trp G✓ ® ❑ ❑ ❑ ❑ ❑ <br /> L ift Pum p Tank/Siphon Chamber ❑ ❑ ❑ ❑ I ❑ ❑ <br /> VIII. RESPONSIBILITY STATEMENT <br /> I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. <br /> Plumber's Name:(Print) Plumber's Signature:(No Stamps) MP/MPRSW No.: Business Phone Number: <br /> Plumber's Address(Street.City,State,Zip Code): <br /> IX. COUNTY/ DEPARTMENT USE ONLY <br /> ❑Disapproved Sanitary Permit Fee 0.,Wdes G,oundwate, at73- % <br /> ue Issuing n igna re ps) <br /> roved harge reel <br /> IF <br /> pp ❑Adverse eterr tial /c�b�/Urr AdverseDeterminaton / J <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> S8I1-6398(n-OS/94) D14N1110TI1N Original to(Douly,One wpy io: Sutely811 fiin,D­,, ,0wn ,,Pl.mb , <br />