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Safety and Buildings Division <br /> ` SC0115%11 SANITARY PERMIT APPLICATION 201 E.Washington Ave. <br /> In accord with ILHR 83.05,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 1/2 x 11 inches in size. "&4 -_�-3S)y <br /> • See reverse side for instructions for completing this application State Sanitary Permit mber <br /> The information you provide may be used b other government agency programs 3 <br /> y p y y g q y p 9 ❑Chec I revision to pr sous application <br /> [Privacy Law,s. 15.04(1)(m)). State Plan I.D.Numl r/ <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INF RMATION ��(JO/ <br /> Property Owner Nam Property Location <br /> E Ar4 1/4 1/4,S 3ST N, R �(o E(or)to c <br /> Prope Owner's Mailing Address Lot N mber r7 <br /> City,Sta a Zip Code Phone Number Sub ision Na or CSM N her <br /> o Tnl. ((,IS ) S� <br /> 11. BUILDING: (check one) ❑ State Owned- ❑ ity Nearest Road -7380 <br /> Village ' r <br /> Public 1 or 2 FamilyDwelling- No.of bedrooms Z Town OF w.f�tJID W- C01� IjZS .RO <br /> III. BUILDING USE: (If building type is public,check all that apply) Parcel TaxNumber(s) <br /> 1 ❑ Apartment/Condo I d;w S <br /> 2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Outdoor Recreati a Facili <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. )6 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 ❑Seepage Bed 21 ❑Mound 30❑Specify Type 41 ❑Holding Tank <br /> 12XSeepage 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/ y/sq.ft.) (Min./inch) Elevation <br /> 3 C5 0 rjQ� .SOp �"" 93.7 Feet qS.0 Feet <br /> TANK Capact VII. INFORMATION in gallons Total #of prefab. Site Fiber- plastic Exper. <br /> Gallons Tanks Manufacturer's Name concrete Con- Steel glass App <br /> New JE Ing structed <br /> Ta�nyks Tanks <br /> Septic Tank or Holding Tank SD 7rS�D El El ❑ ❑ ❑ <br /> Lift Pump Tank/Siphon Chamber .7r�1.7 ❑ ❑ ❑ ❑ ❑ <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 Sign ature*(N tamps) MP/MPRSW No.: Business Phone Number: <br /> I[ Rt) RvwI45 Lt/M}(y�1 $Sl IS-866- jd5l <br /> Plibmber's Ac dress(Street,jiCity,State,Zip Code): <br /> Ealsr jC Vii . <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑Disapproved itarypermit Fee (Include Groundwater ate Issued IssuingA entSig tur N amps) <br /> Fp-proved / 7S ZSurcharge Fee) H6 <br /> pp ❑Owner Given Initial / `L1� (,fU <br /> Adverse Determination <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(R.11/96) DISTRIBUTION: Original to County.One copy To: Safety 8 Buildings Division,Owner,Plumber <br />