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Safety and Buildings Division <br /> SANITARY PERMIT APPLICATION 201 W.Washington Avenue <br /> `4sconsin In accord with ILHR 83.05,Wis.Adm.Code P O Box 7302 <br /> Department of Commerce Madison,WI 53707-7302 <br /> • Attach complete plans(to the county copy only)for the system,on paper not less County Tt <br /> than 8 112 x 11 inches in size. 912 r n(? 233 <br /> • See reverse side for instructions for completing this application State Sanitary Permit Number (� <br /> Personal information you provide may be used for secondary purposes ❑Check if revision to revlo u's a ication W <br /> [Privacy Law,s. 15.04(1)(m)I. State PI I.D.Number <br /> I. APPLICATION INFORMATION- PLEASE PRINT ALL INF RMATION 4 (25-/ <br /> Propert Owner Name Property Location <br /> 01 ,` 1/4 1/4,S Of T 31j,N, R ,rE(or)(0 <br /> Property Own6rs Mailing Address Lot Number Block Number <br /> (0 S v 5 6 v l,,G <br /> City, �I Zip Code .Phone Number Subdivision Name or CSM Number At <br /> �� <br /> /a/ /e Pr vig 097X/ (lo/e ) 1/`ZD— Il a� Svn t' / e�`n <br /> II. TYPE OF BUILDING: (check one) ❑ State Owned ❑ 't1aNearest Road <br /> Vil <br /> Public 1 or 2 FamilyDwelling ❑-No.of bedrooms Townge of LO ee &1, ` c <br /> III. BUILDING USE: (If building type is public,check all that apply) Parcel Tax Number(s) <br /> 1 ❑ Apartment/Condo 0) 3Y^Vdno -Q rmo <br /> 2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ O cor Recre onal Facility <br /> 3 ❑ Campground 7 ❑ Merchandise: Sales/Repairs 11 ❑ Re ar/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. 5fReplacement 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 ❑Mound 30❑Specify Type 4110 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 /> /1Q Required (sq. ft.) Proposed(sq.ft.) (Gals/day/sq.ft.) (Min./inch) Elevation <br /> Feet Feet <br /> TANK Capact <br /> VII. INFORMATION in allons Total #of Manufacturer's Name Prefab- con Steel Fiber- plastic Exper- <br /> New Existin Gallons Tanks Concrete strutted glass App <br /> Tanks Tanks <br /> Septic Tank or Holding Tankk /G1Uo 41 i ESQ { 10 ❑ ❑ ❑ ❑ ❑ <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 /> Plum is Name:(Priv Plum is Signa re:( tam s) MP/MPRS1_ Business Phone Number: <br /> 7o e/^/ ur/an <br /> Plumber' Address(Street,city,State,Zip Code): <br /> 1- // f h 5 > /ter�d ter/ '�, w SyS 3 7 <br /> IX. COUNTY/ DEPARTMENT USE ONLY <br /> ❑Disapproved Sitary Permit Fee (Includes Groundwater ate ssue Issuing AgInt Signature(No Stamps) <br /> Approved E]Owner Given Initial I/�� Surcharge Fee) J�'�/ <br /> Adverse Determination / <br /> _r1t 410 <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398 IRA 1197) DISTRIBUTION: Original to County.One copy To: Safety 8 Buildings Division,Owner,Plumber <br />