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Safety and Buildings Division <br /> V#"n�jn SANITARY PERMIT APPLICATION 201 W.Washington Avenue <br /> P O Box 7302 <br /> In accord with ILHR 83 05,Wis.Adm.Code Madison,WI 53707-7302 <br /> Department of Commerce <br /> • Attach complete plans(to the county copy only)for the system,on paper not less Co my <br /> than 5 irz R 1 n inches in <br /> S ate SanitaryPermltNumber <br /> • See reverse side for instructions for completing this application o prr plicaTOn <br /> evG <br /> Personal information you provide may be used for secondary purposes ❑Cneck if revto s <br /> (Privacy Law,s- 15.04(1)(m)). State Plan I.D.Number <br /> I. APPLICATION INFORMATION-PLEASE PRINT ALL INF RMATI N <br /> Prop Owner Nameope ca ion <br /> 84 L504 Wv4 1/4,5 T p N,R E(o W <br /> Property Owner's Mailing Address Lot Number Block Number <br /> 3 2 3151"- ST- 5 <br /> City,State Zip Code Phone Number r <br /> C ICC 55 12 4151 )Z7-2323 � - <br /> II. BUILDING: (check one) ❑ State Owned !t( Ne rest Road <br /> Vllan ,rye <br /> Public 1 or 2 FamilyDwelling-No.of bedrooms 2 Town of 1v1.+ <br /> III. BUILDING USE: (If building type is public,check all that apply) ParcelTax Nuumber(s) a /� <br /> 1 ❑ Apartment/Condo V 7- 4909 v' Z� <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 /> Tank Only______________ ExlstlnQSystem - Existin <br /> -----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 41 E]Holding Tank <br /> 12 Q E]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) Gt Elevation <br /> 2 � 13-7 Feet 17.0 Feet <br /> VII. TANK <br /> Capacity site <br /> INFORMATION in gallons Gallons Tan Manufacturer's Name Concrete <br /> con- steel glass Plastic APpr. <br /> New Existin strutted <br /> Tanks Tanks <br /> Septic Tank or Holding Tank ank —� 1:1 11E 0 <br /> Lift Pump Tank/Siphon Chamber El ❑ El E <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 tamps) MP/MPRSW No-: Business Phone Number: <br /> P 16 tuber's Address(Street,C!ty,State,Zip Code) <br /> (o0 3S WI <br /> IX. COUNTY/ DEPARTMENT USE ONLY <br /> ❑Disapproved Sanjtarg Permit Fee (Includes Groundwater ate ssue Issuing A e Signa reel a ps) <br /> rcharge ree) <br /> WAOrovedn <br /> Owner Given Initial <br /> Adverse Determination / <br /> X. CONDITIONS PF APPROVAL/REASONS FORDISAPPROVAL: <br /> �b <br /> We,�� db (x ud t'r 4-& sys'� I)Al a <br /> SBD-6398(R.11/97) DISTRIBUTION: Original to County.One copy To: Safety a Buildings Division,Owner,Plumber <br />