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Saf <br /> Visilbonsin SANITARY PERMIT APPLICATION 201 E. ashin to Ave. ion <br /> 201 E.Washington Ave.In accord with ILHR 83.05,Wis.Adm.Code P.O.Box 7969 <br /> Department of Commerce Madison,WI 53707.7969 <br /> 'Y <br /> • Attach complete plans(to the county copy only)for the system,on paper not less County ���)�� <br /> than 81/2 x 11 inches in size. 7 <br /> • See reverse side for instructions for completing this application State Sanitary Permit Nu jr berr <br /> The information you provide may be used by other government agency programs ❑Check it revrevious application <br /> [Privacy Law,s. 15.04(1)(m)]. <br /> State Plan I.D.Number ` <br /> 1. APPLICATION INFORMATION - PLEASE PRINT ALL INF RMATI N { _ <br /> Prope Owner Name P operty L cation <br /> 35 CIV4 172r S 31 T 40 N, R I(, E(CI <br /> Propert Owner's Mailing Address Lot Number r <br /> City, tate - ` �� Zip Code Phone Number Subdivision Name or CSM Number 2 <br /> W 154S11 43-7824 <br /> 11. PE OF BUILDING: (check one) ❑ State Owned oItr Nearest Road <br /> Public 1 or 2 Famil Dwellin - No.of bedrooms Town of AM13W <br /> III. BUILDIN USE: (If building type is public,check all that apply) Parcel TaxNumber(s) <br /> 1 ❑ Apartment/Condo 07-0 '331 OZ 740 <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_ Ivf New 2. ❑ Replacement 3. ❑ Replacement of 4. Reconnection of <br /> X System ❑ 5. ❑ Repair of an <br /> ____ y-------------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 21E]Mound 30 E]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 1 3. Absorp.Area 4. Loading Rate 5. Perc. Rate 6. System Elev. 7. Final Grade <br /> Req ired(sq.ft.) ProoseFeet Feetd(sq.ft.) (GaWday/sq9 1-7 .ft.) (Min./inch) [evation <br /> VII. TANK Capacity <br /> INFORMATION in gallons Total #of Manufacturer's Name Prefab. Site Fiber- Plastic Exper. <br /> New ExistingGallons Tanks Concrete Con- Steel glass App <br /> Tanks Tanks <br /> structed <br /> Septic Tank or Holding Tank n ❑ ❑ <br /> Lift Pump Tank/Siphon Chamber I IJ Q 11 1 El I Q El <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'sSignatue: oStamps) MS � <br /> P//MPR6-5,q <br /> SWWNNo(.: Business Phone N tuber: <br /> J D✓! - <br /> Ll <br /> PI mber's A(dress(Street,Ci y,State,Zip Code) <br /> L_ 6O w ltd — 5 S <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑Disapproved Sanitary Permit Fee (Includes Groundwater ate IssuedIssuing A ent Signature(No S m <br /> roved s a arge Fee) <br /> PP ❑Owner Given Initial c � iJ1.2 <br /> Adverse Determination J 7 7 <br /> CONDITIONS OF APPROVAL/REASONS FORD APPROVAL: <br /> SBD.6398(8.11/86) DISTRIBUTION: Original to County.One copy To: Safety 6 Buildings Division,Owner,Plumber <br />