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Safety and Buildings Division <br /> SANITARY PERMIT APPLICATION 201 W.Washington Avenue <br /> Visconsin In accord with ILHR 83.05,Wis.Adm.Code P O Box 7302 <br /> Department of Commerce Madison,WI 53707-7302 <br /> 1. <br /> • Attach complete plans(to the county copy only)for the system,on paper not less County <br /> than 8 1/2 x 11 inches in size. J <br /> • See reverse side for instructions for completing this application State Sanitary <br /> /Permit Nuf9ber <br /> Personal information you provide may be used for secondary purposes ❑Ch i vi ion to revlous application <br /> [Privacy Law,s. 15.04(1)(m)]. State Plan I.D.Number <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INF RMATI N <br /> Propi%rly Owner meroperty Location <br /> A49 1/4 1/4,S J5 T40 ,N, R /4E(or) <br /> Property Owner's MailinglAddress Lot Number Block Number <br /> 7-SS-73 IRcN SLJFrJO LK. D <br /> City,StateI'll. Zi Code Phone Number Subdivisi IT a eorCSMNumber <br /> 1( 16)259-1959 5 <br /> II. TYPE OF BUILDING: (check one) ❑ State Owned ❑ %-ILY Nearest Road <br /> ❑ Village <br /> Public 1 or 2 FamilyDwelling-No.of bedrooms 3 own OF,SCAD-,I (-1- <br /> IrL Rn <br /> III. BUILDIN USE: (If building type is public,check all that apply) Parcel Tax <br /> NNuumber((s) 2 <br /> 1 E] Apartment/Condo A-" 711 VJ 7200 <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. 'g( New 2, ❑ Replacement 3. ❑ Replacement of 4. ❑ Reconnection of S. ❑ Repair of an <br /> System --------System ------------- Tank Only---------------Existing System ________ ExistingSystem <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 I§Seepage 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 S. Perc. Rate 6. System Elev. 7. Final Grade <br /> Required(sq.ft.) Proposed(sq.ft.) (Gals/day/sq.ft.) (Min./inch) Elevation <br /> 450 -7 75& . 6 0-- 95-3 Feet $_o Feet <br /> Ca aclt <br /> VII• INFORMATION Manufacturer's TANK in gallons Total #of MName Prefab' Con Steel Fiber- Plastic Site Aper. <br /> New Existin Gallons Tanks concrete strutted glass App. <br /> Tanks Tank <br /> Septic Tank or Holding Tank 000 10 I? ❑ ❑ ❑ ❑ ❑ <br /> Lift Pump Tank/Siphon Chamber --L-+- ❑ ❑ ❑ ❑ ❑ ❑ <br /> Vlll. 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 tamps) MP/MPRSW No.: Business Phone Number: <br /> Y,JCAA?,o f'kl>JS 34Z� r5' (06 - r5 <br /> P mber's Address�treet,�City,St te,Zip Code): 893 <br /> WV 15- \j6ssim, 1 L7 <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> Disapprove Sanitary Permit Fee 0"clu,esti'm ndwater ate ue Issuin tSrn : ( ps) <br /> roved ❑Owner Given Initial �J surcbargePee) 17 Al <br /> Ud Adverse Determination CT�� <br /> X. CONDITIONS OF APPROVAL/REASONS FOR ISAPPROVAL: <br /> SBD-6398(R.11/97) DISTRIBUTION: Original to County.One copy To: Safety 8 Buildings Division,Owner,plumber <br />