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c`T2?C-c7-rzo <br /> Safety and Buildings Division <br /> `� - SANITARY PERMIT APPLICATION 201 E.Washington Ave. <br /> ►sconsin In accord with[LHR 83A5,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 Count <br /> than 8112 x 11 inches in size. NDN �0 1 <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 <br /> Y P Y Y 9 9 Y P 9 ❑Check if revision to previous application <br /> [Privacy Law,s. 15.04(1)(m)]. State Plan I.D.Number <br /> I. APPLICATION INFORMATION- PLEASE PRINT ALL INFORMATION – <br /> Prop rty Owner Na e r Property Location <br /> I^oi s�1/ay/„Jt/a,5 67,? T y0 ,N, R /S E(or 6W <br /> Property Owner's Mailing AddressLot Number .Block Number <br /> 49 7 / i9-cl e.-J W <br /> City,StateZip Code Phone Number Subdivision Name or CSM Number <br /> e 1�e� �.✓s _e ( )ALL-7LS7 — <br /> I1. TYPEF BUILDING: (check one) E] State Owned ❑ city Nearest Road <br /> Public 1 or 2 FamilyDwelling ❑ vilage-No.of bedrooms Town OF J_Ar <br /> III. BUILDING USE: (If building type is public,check all that apply) Parcel TaxNumbberr(s) <br /> 1 ❑ Apartment/Condo 9/.;? 0 3 80 e-) <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. M New 2. ❑ Replacement 3. ❑ Replacement of 4_ ❑ Reconnection of 5. ❑ Repair of an <br /> ____ ystem ________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 RISeepage 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 /> J s Y 6 � � Feet 9� Feet <br /> TANK Capact <br /> VII. INFORMATION in allons Total #of Manufacturer's Name Prefab- Con- steel Site fiber- plastic Exper- <br /> New Existin Gallons Tanks Concrete strutted glass App <br /> Tanks Tanks <br /> Septic Tank or Holding Tank ��Q Qr7(� /�z¢� 19 ❑ ❑ ❑ 101:1Lift Pump Tank/Siphon Chamber ❑ El El [a] ❑ ❑ <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 Ac dress(Street,City,State,Zip Code): <br /> koro� �-! Slr�icJ G✓�" 54��7� <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑Disapproved Sanitary Permit Fee (includes Groundwater ate IssuedIssuing Agen Signature(N St ps) <br /> roved Tur ha a Fee) <br /> p ❑Owner Given Initial 7 cel <br /> Adverse Determination / <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398 IRA 1/96) DISTRIBUTION: Original to County,One copy To: Safety 8 Buildings Division,Owner,Plumber <br />