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SAN ITA RY PERMIT APPLICATION 201eE.Wasand hington Buildings <br /> Aveinion <br /> NAsconsin 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 Countt <br /> than 8 112 x 11 inches in size. ,� L(/t AJ e OS�S� X114 <br /> • See reverse side for instructions for completing this application state Sanitary ermit NttmbeV 0 <br /> �LI/�75 /�/� l/ QJ <br /> The information you provide may be used by other government agency programs E]Check if revision to previous application n <br /> [Privacy Law,s. 15.04(1)(m)]. L <br /> State Plan I.D.Numb e <br /> 1. APPLICATION INFORMATION - PLEASE PRINT ALL INF RMATION <br /> Property Owner Name Property Location <br /> Q/1�e �� �j�� J 1/4 1/4,S0?5– T t16 N, RJ5`E(or)1'&) <br /> Propert 0 ne 'Mailp Address Lot Number BIpcIr Nu J;ter <br /> 19 0 , Z <br /> I,St a e / Zip Code;,,,,_ Phone Number Subdwuioalya.me or CSM Number <br /> �. v 3 <br /> II. TYPE F BUILDING: (check one) ❑ State Owned ❑ Icy Nearest Road <br /> ❑ Thane ^ ,4 .5 <br /> El Public 1 or 2 FamilyDwelling-No.of bedrooms -2 Town of�.J <br /> III. BUILDING USE: (If building type is public,check all that apply) Parcel Tax Number(s) <br /> 1 ❑ Apartment/Condo 6?/�— `r(6�6 01 709 <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_ r Replacement 3. ❑ Replacement of 4. E] Reconnection of 5_ E] 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 RSeepage 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 5. Perc. Rate 6. System Elev. 7. Final Grade <br /> Required(sq. ft.) Proposed(sq.ft.) (Gals/day/sq.ft.) (Min./inch) c7 -7 Elevation <br /> �, © v cy� , Y7 / S' / Feet 7Z,oZ Feet <br /> TANK Ca aclt <br /> VII. In INFORMATION Ballo s Total #of Manufacturer's Name Prefab. cow A <br /> steel Fiber- Plastic p <br /> New Existin Gallons Tanks Concrete structed glass App. <br /> Tanks Tanks <br /> Septic Tank or Holding Tank j3U SWo 0 ❑ ❑ ❑ ❑ ❑ <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 /> Plumber's Name:(Print Plumber's signature:(Noamps) MPlMPRSWNo.: Business Phone Number: <br /> v7�-7GJr� <br /> Plumber's Ac dress(Street,City,State,Zip Code): <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> [:]Disapproved Sanitary Permit Fee (IncludesGroundwater ate ssue Issuing Age t S nat a(No m s) <br /> Approved ❑Owner Given Initial Sur argefee) <br /> Adverse Determination ��/rJ <br /> X. CONDITIONS OF APPROVAL/REASONS FOR D SAPPROVAL: <br /> SBD-6398(R.11/96) DISTRIBUTION: original to county,One copy To: Safety 8 Buildings Division,owner,Plumber <br />