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SANITARY PERMIT APPLICATION �>!v 201eE shingtongAve. <br /> Visconsin 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 tie x 11 inches in size. zE-17- --?cRS <br /> • See reverse side for instructions for completing this application State Sanita�ryy PermitNumber <br /> The information you provide may be used by other government agency programs ❑Check if r✓'arsi t previviouus4pplication <br /> [Privacy Law,s. 15.04(1)(m)]. <br /> State Plan I.D.Number <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INF RMATI N <br /> Property Owner NAme E-1 Property Location <br /> ilYpi 1/4 34l 1/4,5 .�a T_7�j N, R (or)W <br /> Property Owner s Mailing Addre;s Lot Number Block Number <br /> If � "7r vt <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> ( <br /> © CE-O/ A irr L•ac: /5— — b <br /> 11. ILD G: (check one) E] State Owned 'ty Nearest Road <br /> Public or 2 Famil welling-No.of bedrooms � j vowan OF � Gc'�/ HUI7-v,4 <br /> III. BUILDING USE: (If building type is public,check all that apply) Parcel TaxNumber(s) <br /> 1 (] Apartment/Condo 6,:9 8 e;,) 135— tom- (Do <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. ❑ Replacement 1 ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an <br /> ____System --- - -System - -- TankOnlyN - Existing System ------__-ExistingSystem <br /> 8) E] A Sanitary Permit was previously issued. Permit Number Date Issued <br /> V. TYPE OF SYSTEM: (Check only one) <br /> Non-Pressurized Distribution Pressurized Distri ti x rimental r SY' N <br /> 11 ❑Seepage Bed 21 ❑Mound ❑Specify TypeC Holding Tank <br /> 12 R eepage Trench 22❑In-Ground Press /�JJ �y�' 2❑Pit Privy <br /> 13❑Seepage Pit s I 43❑Vault Privy <br /> 14❑System-In-Fill j <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 /> 7,1:`_ 75.3' 0 Feet <br /> Capcit <br /> VII. TANK in allo 5 Total #Of Prefab. Site Fiber- Exper <br /> INFORMATION Gallons Tanks Manufacturers Name Concrete st Con- Steel Plastic <br /> New Existin glass App. <br /> Tanks Tanks rq� <br /> Septic Tank or Holding Tank top u <br /> o0 � f}W ❑ ❑ ❑ ❑ ❑ <br /> Lift Pump Tank/Siphon Chamber ❑ ❑ ❑ ❑ ❑ ❑ <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:(N Stamps) MP/MPRSW No.: Business Phone Number: <br /> Plumber's Address(Street,City,State,Zip Code): <br /> 7,3/ zAft ,V4 �,�_NeAk <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> 11 Disapproved nitary Permit Fee (Includes Groundwater ate issuedIssuing A t Signat a(No s) <br /> Su <br /> proved ❑Owner Given Initial � O� rcharge Fee) <br /> ��3�� <br /> Adverse Determination <br /> X. CONDITIONS OF APPEOVAL/R/`EASOJHS�FOR D SAPPROVA�L: D�r <br /> SBD6398 tA.111B6) DISTRIBUTION: Original to County,One copy To: Safety 8 Ro Miogs Division.Owner,Mweber <br />