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Safety and Buildings Division <br /> SANITARY PERMIT APPLICATION 201 W.Washington Avenue <br /> Vsconsin In accord with[LHR 83.05,Wis.Adm.Coe P O Box 7302 <br /> Code Department of Commerce Madison,WI 53707-7302 <br /> • Attach complete plans(to the county copy only)for the system,on paper not less County K�� J�� <br /> than 8 1/2 x 11 inches in size. <br /> • See reverse side for instructions for completing this application State Sanitar2Permit Number <br /> Personal information you provide may be used for secondary purposes �`��4� <br /> [Privacy Law,s. 15.04(1)(m)]. ❑Check it revision to previous pplication <br /> State Plan I.D.Number <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INF RMATI N <br /> Property Owner Name Property Location <br /> 4 1/4 1/4,S 3 T � ,N, R E(or)(i�) <br /> Property Owner's Mailing d ress bet tdvmber Block Number <br /> � 3 3 15 Ue , c/. G,L, <br /> Cit ,StateZi Code Phone Number Subdivision Name or CSM Number <br /> :re�J W - O ( )_7W ? <br /> H. TYPE OF BUILDING: (check one) ❑ State Owned El City Nearest Road <br /> ❑ <br /> Public 1 or 2 Family Dwelling Villag <br /> -No.of bedrooms Towne <br /> OF , 1Uv e,1 w 70 <br /> III. BUILDING USE: (If building type is public,check all that apply) Parcel TaxNumber(s) � / <br /> 1 ❑ Apartment/Condo O o � � 7//3 6 / m o p <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. 56 New 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an <br /> ------SSystem --------System ----- ------- Tank Only SSSS SSSS - 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 L&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 Pe77Y-1 <br /> 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) c� Elevation <br /> U D cid a C9 4 i �' "–" /S.� Feet 7i7 Feet <br /> VII. TANK in Ca gct <br /> gallons Total #OfPrefab. Site Fiber- Plastic Exper <br /> INFORMATION New ExistingGallons Tanks Manufacturers Name Concrete Con- Steel glass App_ <br /> structed <br /> Tanks Tanks <br /> Septic Tank or Holding Tank rato a 0 El <br /> Lift Pump Tank/Siphon Chamber El ❑ ❑ 1 1:1 Cr ❑ <br /> Vill. RESPONSIBILITY STATEMENT <br /> I,the undersigned,assume responsibility for installation of the onsite sewage system shown on the attached plans. <br /> Plumber's Name:(Prin Plumber's Sign tures o Stamps) MP/MPRSW No: Business Phone Number: <br /> Plum er's Address(Street,City,St9te,Zip Code): <br /> o ��/ _5 rv%le.") e__1 -5Y�7a <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑Disapproved Sanitary Permit Fe (includes Groundwater Date Issued Issuing t Signa r=St <br /> proved El Given Initial /�Q surcharge Fee) <br /> Adverse Determination <br /> vwl <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 />