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Safety and Buildings Division <br /> y /� SANITARY PERMIT APPLICATION 201 W.Washington Avenue <br /> P O Box 7302 <br /> ►scons►n In accord with ILHR 83.05,Wis.Adm.Code Madison,WI 53707-7302 `\ <br /> Department of Commerce T' <br /> t less coun <br /> • Attach complete plans(to the county copy on for the system,on paper not �t- 7 <br /> than 81/2 x 11 inches in size. State Sanitary Permit Number <br /> • See reverse side for instructions for completing this applicationd 334 <br /> Personal information you provide may be used for secondary purposes ElCheck if revision o previous application <br /> [Privacy Law,s. 15.04(1)(m)1- State Plan I.D.Number <br /> I. APPLI ATI N INFORMATION - PLEASE PRINT ALL INF RMATION <br /> Property Location <br /> pPropeOwner Name 1/4 1/4,5 '7T ,N, R 4- E(or� 1zT E/Q Number <br /> Owner's Mailin Address4 S3il4po K/ us D2- <br /> tfe Zip Cod2ePrCSMNu ber 3 ( ` p Nearest Road IL G: (check one) ❑ State Owned village <br /> Public N. <br /> or 2 Famil Dwelling-No.of bedrooms -7 Town of R <br /> III. BUILD[ G USE: (If building type is public,check all that apply) <br /> arcel Tax Numbers) <br /> 2$ 315- o son <br /> 1 ❑ Apartment/Condo 10 Outdoor Recreational Facility <br /> 2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home <br /> ❑ Restaurant/Bar/Dining <br /> 3 [3 Campground <br /> Campground 7 ❑ Merchandise:Sales/Repairs ❑ <br /> Mobile Home Park 12 ❑ Service Station/Car Wash <br /> 4 ❑ Church/School $ [1 <br /> 5 ❑ Hotel/Mote[ 9 C] office/Factory 13 E] Other: specify <br /> IV. TYPE OF PERMIT: (Check only one box on line A. Check box on line B,if applicable) Repair of an <br /> �(New 2, ❑ Replacement 3_ ❑ Replacement of 4. ❑ Reconnection of 5. ❑ p . <br /> A) 1. Existin System Exlstln System{�,� Tank Only ----g--t----------------- - ---- <br /> / -S stem System --------------------y-------------- <br /> Y -- <br /> Date Issued <br /> B) ❑ A Sanitary Permit was previously issued. Permit Number <br /> V. TYPE OF SYSTEM: (Check only one) Other <br /> Non-Pressurized Distribution Pressurized Distribution Experimental Holding Tank <br /> 11 g(Seepage Bed 21 ❑Mound 30❑Specify Type 41 ❑ g <br /> y� 22 In-Ground Pressure 42[1 Pit Privy <br /> 1 Seepage Trench ❑ 43❑Vault Privy <br /> 13❑Seepage Pit <br /> 14❑System-In-Fill <br /> VI. ABSORPTION SYSTEM INFORMATION: 7. <br /> 1.Gallons Per Day 2. Absorp.Area 3. Absorp.Area 4. Loading Rate 5. Perc. Rate 6. System Elev. E vl tion rade <br /> Requyr q.ft-) Pro sed q.ft.) (Gals/day/sq.ft.) (Mi ) Gds �! Feet 11 Feet <br /> 10 <br /> VII. TANK Capaelty Prefab. Site Fiber- plastic Exper <br /> in gallons Total #of Manufacturers Name Concrete Con- Steel glass APP <br /> INFORMATION New Existin Gallons Tanks structed <br /> Tanks Tanks <br /> Septic Tank or Holding Tank wC/ <br /> Lift Pump Tank!Siphon Chamber <br /> Vlll. RESPONSIBILITY STATEMENT <br /> I,the undersigned,assume responsibility for installation of the onsite sewage system shown on the attached plans. <br /> MP/MPRSW No.: Business Phone Number: <br /> Plumber's Name:(Print) PlumblsSignature: 05 ps) <br /> tIY/yiM.(�/ <br /> PI ber'Address(Street,City, tate,Zip Code): <br /> 2"7 o95- <br /> Ix. <br /> S <br /> IX. COUNTY/DEPAIRTIVENT USE ONLY <br /> ❑Disapproved Sanitary Pe I lee (includes Groundwater raee IssuingA9en S' nature o a S) <br /> �"' e9v hargeFee)Approved ❑Owner Given Initial jf� �� <br /> Adverse Determination <br /> X. CONDITIONS OF APPROVAL/REASONS FOR ISAPPROVAL: <br /> DISTRIBUTION: Original to County,one copy To: Safety&Buildings Division,owner,Piumber <br /> SBD-6398(R.11/97) <br />