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Safety and Bui din s Divisi n <br /> Visitonsin SANITARY PERMIT APPLICATION 201 W.Washington Avenue <br /> P O Box 7302 <br /> Department of Commerce In 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 81/2 x 11 inches in size. &4j1fA/4-7T �� <br /> • See reverse side for instructions for completing this application State Sanitary Permit Number <br /> Personal information you provide may be used for seconds �� �� ' <br /> y p y secondary purposes ❑Check if r ision to previous application <br /> (Privacy Law,s. 15.04(1)(m)]. State Plan I.D.Number <br /> I. APPLICATION INFORMATION- PLEASE PRINT ALL INF RMATION Ap <br /> Propert Owner Name / Property Location <br /> LO 56U1/a ,u� t/a,5 T �( ,N, R /!P E(or <br /> Property Owner'SMailing Address Lot Number Block Number <br /> lq 6 Sh`T0149 1 41AE_ <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> M�"70172522i 1 Mti 55-1115- (4 57 ) 121,--25zo <br /> 11. TYPE OF BUILDING: (check one) ❑ State Ownedotyy Nearest Road <br /> Public 1 or 2 FamilyDwellingTowa-No.of bedrooms ° n OF Sufi ss /y//(/L- f/ v/1nl '20 <br /> III. BUILDINGUSE: (If building type is public,check all that apply) Parcel TaxNumber(s) <br /> 1 ❑ Apartment/Condo 0 Z5.;t -53 -of—?oo <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.'�f Replacement 3. Replacementof 4. [:] Reconnection of 5. E] Repair of an <br /> System _ System -__ Tank Only- ___________ Existing System----------Exi sting System <br /> B) ❑ A Sanitary Permit was previously issued. Permit Number S10Ig Date Issued <br /> V. TYPE OF SYSTEM: (Check only one) <br /> Non-Pressurized Distribution Pressurized Distribution Experimental Other <br /> 11 b Seepage Bed 21 E]Mound 30 E]Specify Type 41 ❑ Holding Tank <br /> 12 E] eepage 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) I / Elevation <br /> �� 6- c/q-7 Feet 97ZLl <br /> -//5oFeet <br /> Capac <br /> VII. FORMATION in llons Total #of Prefab. Site Fiber- Exper. <br /> g Gallons Tanks manufacturer's Name concrete con- steel glass Plastic App <br /> New ExistIn structed <br /> Tanks Tanks LtJ�I^ - <br /> Septic Tank or Holding Tank /0,1010co ❑ ❑ ❑ ❑ ❑ <br /> Lift Pump Tank/Siphon Chamber ❑ ❑ ❑ ❑ ❑ ❑ <br /> VIII. RESPONSIBILITY STATEMENT <br /> 1,the undersigned,assume responsibility for installation of the onsite sewage system shown on the attached plans. <br /> Plum er's Name:(Print) Plu ie: S ) MP/MPRSW No.: Business Phone Number: <br /> ©ti ti/) E �iPOF�rT a o2(oCo7 D ?/S <br /> Plumber's Address(Street,City,State,Zip Code): <br /> 167/3 so - 57A7E el) 601-- s483o <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑Disapproved sanit y Permit Fee (Includes Groundwater ate IssuedIssuing Age t natu ( s <br /> (Approved ❑ an <br /> rcharge Fee) y0 <br /> "`l Owner Given Initial --J�7tt4���/ 7 S z� <br /> Adverse Determination <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(R.4/99) DISTRIBUTION: Original to County,One copy To: Safety&Buildings Division,owner,Plumber <br />