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r Y" ety and Buildings Division <br /> SANITARY PERMIT APPLICATION 201 W.Washington Avenue <br /> Asconsin P 0 Box 7302 <br /> Depaft0ent of Commerce 1n accord with comm 83.05,Wis.Adm.Code Madison,WI 53707-7302 <br /> • Attach complete plans(to the county copy only)for the system,on paper not less County <br /> than 8 fa x 11 inches in size. J!&Jakem iz3 a3/2 <br /> • See reverse side for instructions for completing this application State Sanitary Perrmit NtImbeer <br /> Personal information you provide may be used for secondary purposes ❑Check revision roprv 6t1r5pplicatlon <br /> [Privacy Law,s. 15.04(1)(m)I. State Plan I.D.Number 4 <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INF RMATI N <br /> Property Owner Name hSubdivision <br /> roperty Location <br /> L. <br /> 1/4 114,S $ T IN,R l'1 E(o <br /> MARK Propert Owner's Mailing Address umber er <br /> $ . RP. 1,E I-Z <br /> City,State ZcjD�Code Phone Number 0 N3ame or CSMyyprber <br /> 11. TYPE B N : (check one) ❑ State Owned - y Nearest Road <br /> 0 Village <br /> Public 1 or 2 Family Dwelling-No.of bedrooms kriTown of IAtJ 10 .1 F <br /> III. BUILDING USE: (If building type is public,check all that apply) Parcel Tax <br /> ,N,umber(s) <br /> 1 E] Apartment/Condo "r— 4409 03 100 <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.,g Replacement 3, ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an <br /> System ________System _____________ Tank Only______________ Existin�System ________ Existing System <br /> B) [3 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 /> 11Seepage Bed 21 E]Mound 30 E]Specify Type 41 []Holding Tank <br /> 12 <br /> 11t <br /> 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 /> // Re wired(sq.ft.) Pro osed(sq.ft.) (Gals/day/sq.ft.) (Min./inch) QElevation <br /> (POO S$ 964 e 7 ��� q4•-2 Feet 9 _ Feet <br /> TANK Ca acit <br /> VII. INFORMATION in gallons otal #of Manufacturer's Name Prefab. it Steel Fiber- plastic Exper. <br /> New Existin Gallons Tanks Concrete structed glass App. <br /> TankTanks- <br /> Septic <br /> nks <br /> Septic Tank or Holding Tank ❑ ❑ ❑ ❑ ❑ <br /> Lift Pump Tank/SiphonChamber 75 ❑ ❑ ❑ ❑ ❑ <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 mps) MP/MPRSW No.: Business Phone Number: <br /> ic�}�IRo NOPKrN1S ? <br /> Plumber's Address(Street,City,State,Zip Code): <br /> 2'17(o0 3 Q4LVW gUJI - <br /> IX. COUNTY/DEPAIRTMENT USE ONLY <br /> E]Disapproved SanijaryPermitFee tlncludesGroundwater ate ssue Issuing entSignature(NoStamps) <br /> yApproved Q / - surcharge Fee)❑Owner Given Initial (y 0n r) �(Ar' <br /> Adverse Determination <br /> X. CONDIIIjS OF APPROyAL/RE SONS FOR DISAPPROVA <br /> ��11 �y Sj e��ts Tb �rtc� cc�7r� Cove ©t- -rn-s 11{� C bel (eh44 <br /> ? s � <br /> [CIA rhao > 3au�e St-,dei i <br /> SBD-6398(R.4/99) DISTRIBUTION: Original to County.One copy To: Safety Is Buildings Division,Owner,Plumber <br />