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��.C( <br /> SANITARY PERMIT APPLICATION ( /-201 E.W shngtonAveision <br /> Visconsin In accord with[LHR 83 O5,Wis.Adm.Code P.O.Box 7969 <br /> Department of Commerce Madison,WI 53707-7969 <br /> • Attach complete plans(to the county copy only)for the system,on paper not less County <br /> than 8 12 x 11 inches in size. BORAlETT <br /> • See reverse side for instructions for completing this application State Sanitary Per miitt NNuum�b r <br /> The information you provide may be used by other government agency programs C]Check it revi;; to previa s app Il'c`ation <br /> [Privacy Law,s. 15.04(1)(m)]. State Plan I.D.Number <br /> 1. APPLICATION INFORMATION - PLEASE PRINT ALL INF RMATION <br /> Property Owner Name Property Location IA <br /> Pic k HARDER �W j 1/4,S 3 T j Pl ,N, R /` flor)W <br /> Property Owner's Mailing Address Lot Number Block Number <br /> 1/9 "ib DR;vE <br /> City,State Zi Code Phone Number Subdivision Name o SM Num r a � <br /> yez iritic p �6g � - L-- 11 • ° I <br /> 11. TYPE OF BUILDING: (check one) ❑ State Owned ❑ ity Nearesf Road <br /> Public or 2 FamilyDwelling- No.of bedrooms Village <br /> own OF <br /> III. BUILDING USE: (If building type is public,check all that apply) Parcel <br /> /Tax Nummber(s) / 2 <br /> 1 ❑ Apartment/Condo <br /> " � ` — 3` a `� O� <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. &!rew 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 YTSeepage 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 /> r �j 6�� Feet meet <br /> Capaclt <br /> VII. N ORMATION in allo s Total #of Manufacturer's Name Prefab. Site <br /> Fiber- Plastic Exper <br /> New Existin Gallons Tanks Con-structed Steel glass App. <br /> Tanks Tanks <br /> Septic Tank or Holding Tank 1666 /004) 1 A1!) ❑ ❑ ❑ ❑ ❑ <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 /> ma:(Print) Plumber's Signature:(N Stamps) /MPRSW No.: Business Phone Number: <br /> o O /S– 35 <br /> Code): <br /> YELL E ,' 8 7 <br /> IT USE ONLY <br /> Sanitary Permit Fee (Includes Groundwater ate IssuedIssuing Age t S' natur No Sta p <br /> l charge Feel <br /> [ initial (J'- -' 7-�' <br /> ermination <br /> OVAL/REASONS FOR DISAPPROVAL: <br /> DISTRIBUTION: Original to county.One copy To: Safety 8 Buildings Division,Owner,Plumber <br />