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Safety and Buildings Division <br /> SANITARY PERMIT APPLICATION 201 E.Washington Ave. <br /> Wisconsin 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 8 112 x 11 inches in size. <br /> • See reverse side for instructions for completing this application S ate Sanitary Permit N mber <br /> The information you provide may be used by other government agency programs 33 6 a.5 <br /> ❑Check it revision to previous application <br /> (Privacy Law,s. 15.04(1)(m)]. State Plan I.D.Numb r <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION <br /> Property Owner Name Property Location <br /> 7:Si7}}4 1ij 1i4 1/4,5 Iq T ,N, R 14 E(or 1@ <br /> Property Owner's Mailing Address Lot Number <br /> O SPAR. 2- <br /> City, t to Zip Code P one Number Subdivi ion Name or CSM N mber <br /> i�I- ..a5 O > <br /> III. TYPEB IL ING: (check one) ❑ State Owned~ ❑ !t� Nearest Road <br /> VII age <br /> Public 1 or 2 Family Dwelling-No.of bedrooms �_ Town of <br /> III. BUILDING USE: (If building type is public,check all that apply) Parcel TaxNumber(s) <br /> 1 ❑ Apartment/Condo I 02S 4{tq 08 & P <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 3. ❑ Replacement of 4_ ❑ Reconnection of 5_ ❑ Repair of an <br /> __System --_ _ System __---_-_--- Tank Only ---_------- - Existing System _ _ Existing System <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 []Seepage Bed 21 WIVIound 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 5. Perc. Rate 6. System Elev. 7. Final Grade <br /> Required(sq. ft.) Proposed(sq.ft.) (Gals/day/sq.ft.) (Min./inch) a Elevation <br /> 40 16 (, Z 97-4- Feet 99 .7 Feet <br /> Ca pact VII. INFORMATION in gallons Total #of Manufacturer's Name Prefab. Con- Fiber- Exper <br /> New ExistingGallons Tanks concrete strutted steel <br /> glass Plastic App <br /> Tanks Tanks <br /> Septic Tank or Holding Tank I I 0D IvIaD ❑ ❑ ❑ ❑ ❑ <br /> Lift Pump Tank/Siphon Chamber r%n VV ❑ ❑ ❑ I ❑ ❑ <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 IA RSW No.: Business Phone Number- <br /> &9492 1-267S-51 IS-S ii!k 445 7 <br /> PI mber's Ar dress(Street,City,State,Zip Code): <br /> -; "_APo fiwy 26 WESSIVEA W1 . 54 13 <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑Disapproved Sanitary Permit Fee (Includes Groundwater Date Issued Issuin A nt Si natu e( Stamps) <br /> Approved I ❑Owner Given Initial r-1.0-- &141ircharge Fee) Q <br /> Adverse Determination <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBO-8398(R 11/96) DISTRIBUTION: Original to County,One copy To: Safety 8 Buildings Division,Owner,Plumber <br />