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G cern <br /> `*6's Safety and Buildings Division <br /> ,• SANITARY PERMIT APPLICATION 201 W.Washington Avenue <br /> onsin 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 �,r/� <br /> than 8 1/2 x 11 inches in size. G SWeTr C; <br /> • See reverse side for instructions for completing this applicatio State Sanitary Permit Number <br /> Personal information you provide may be used for secondary purposes %�, ❑cher CK 5 <br /> It revision to previous application <br /> [Privacy Law,s. 15.04(1)(m)]. l State Plan I.D.Number A i — <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION <br /> Property Owner Name P operty Location <br /> t/a X 1/4,S !q T4J N, R s E(or W <br /> Propert Own e s Mailing Address Lot Number 8i11ber <br /> A <br /> CO3 State Zip Code ( Vfrl <br /> qfZ�Q576324-7-772 // <br /> Phone Number Subdivisiae q Numb �' <br /> . / <br /> II: TYPE OF 1 DING: (check one) ❑ State Owned o Ity Nearest Road <br /> ❑ Village <br /> Public 1 or 2 FamilyDwelling-No.of bedrooms Town OF S$ . <br /> III. BUILDIN USE: (If building type is public,check all that apply) ar ITaxNumber(s) wo <br /> 1 ❑ Apartment/Condo 1 d 3a ria N �Q 6 - <br /> 2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Hom 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, E] Replacementof 4_ E] Reconnectionof 5_ E] Repair of an <br /> _ System ________System_____ _______ TankOnly---------------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 M Seepage Bed 21 C]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/da /sq.ft.) (Min./inch) (� / Elevation <br /> ".50 0 Z- r' 9� -! Feet 7,4 Feet <br /> Ca acct <br /> VII Fiber- <br /> INFORMATION in allo s Total #of Prefab. Site Fiber- Exper. <br /> g Gallons Tanks Manufacturer's Name concrete Con- steel glass Plastic App <br /> New Existin structed <br /> Tanks Tanks A <br /> Septic Tank or Holding Tank a to ❑ 130 13 El <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'(N mps) MP/MPRSW No.: Business Phone Number: <br /> ss 11115-966- S <br /> P mber'SA dress Street,City tate,ZipCode)- <br /> 0 35' WCOMISk WE S <br /> IX. COUNTY/DEPARTMf NT USE ONLY <br /> ❑Disapproved Sanit ry Permit Includes Groundwater ate IssuedIssuing Ag nt 'CJ natU ( a s) <br /> A roved urc rgeFee) 10 -3-78 <br /> pp ❑Owner Given Initial � T� _ <br /> Adverse Determination <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398 IRA 1/97) DISTRIBUTION: Original to County.One copy To: Safety&Buildings Division,Owner,Plumber <br />