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C z2 <br /> afety and Buildings Division <br /> Visconsin SANITARY PERMIT APPLICATION 201 W.Washington Avenue <br /> In accord with ILHR 83.05Wis.Adm.Code P O Box 7302 <br /> Department of Commerce Madison,WI 5370, 7-7302 _ <br /> • Attach complete plans(to the county copy only)for the system,on paper not less County / ? / <br /> than 8112 x 11 inches in size. 1 L r <br /> • See reverse side for instructions for completing this application Sta-teSanitary ermi umber <br /> Personal information you provide may be used for secondary purposes ❑Check it revlslonn ttosprevious saapplicatioonn <br /> [Privacy Law,s. 15.04(1)(m)]. State Plan I.D.Num r <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INF RMATION <br /> Propertyt 0yvner Name Property Location <br /> 114 114,S T40 N,R E(or) <br /> Propert Owner's ailing Addre s Lot Numbers Block Number <br /> Cit ,Slate Zip Code Phone N ber Sub d vision Na a or CSMumber <br /> LLQ sO 1( ) V. <br /> TYPE OF BUIL : (check one) ❑ State Owned ❑ Ity Nearest Road Q <br /> ❑ Village <br /> Public 1 or 2 FamilyDwelling-No.of bedrooms �_ mITown o, _4CEM x4W.ScoAl <br /> 111. BUILDING USE: (If building type is public,check all that apply) Parcel Tax Number(s) <br /> 1 ❑ Apartment/Condo 01-$ 93DO - 02.' ZDb <br /> 2 ❑ Assembly Hall 6 ❑ Medica[ 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 xpp line B,if applicable) <br /> A) 1. ❑ New 2. ❑ Replacement g; f 4. ❑ Reconnection of 5. ❑ Repair of an <br /> _--_ System _ System ________ __--Tank --- _____________ Existing System _________ExistngSystem <br /> B) Sanitary Permit was previously issued. Permit Number Sg 4 63 Date Issued Z7 <br /> V. TYPE OF SYSTEM: (Check only one) <br /> Non-Pressurized Distribution Pressurized Distribution Experimental Other <br /> 11 J$(Seepage 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-(n-Fill <br /> VI. ABSORPTION SYSTEM INFORMATION: <br /> 1.Gallons Per Day 2. Absorp.Area 3. Absorp.Area 4!oading Rate S.Perc. Rate 6. System Elev. 7. Final Grade <br /> Required(sq.ft.) Proposed(sq.ft.) (Gals/da /sq.ft.) (Mi int Q vation <br /> Oa 'L 2.- p-�ZFeet Feet <br /> VII. TANK apacity site <br /> r. <br /> INFORMATION in gallons Total lis Tanks Manufacturer's Name Cone este Con- steel Fiber- <br /> Plastic App- <br /> New Existin strutted <br /> Tank Tanks <br /> Septic Tank or Holding Tank 50 1 10166Z ❑ 1:11 ❑ I ❑ ❑ <br /> Lift Pump Tank/Siphon Chamber I I 1 ❑ ❑ ❑ ❑ ❑ ❑ <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:(No Stamps) MP/MPRSW No.: Business Phone Number: <br /> Gq A, r 5- X66- 4is <br /> P tuber's Address(Street,City,State Zip Code): <br /> S E&qTFJZ W <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> w ` ❑Disapproved Sanitary Permit Fee (includes 7jatee IssuingAge tSi ature( St <br /> oved ❑Owner Given Initial - harge Feet Adverse Determination <br /> X. CONDITIONS OF APPROVAL/REASONS FOR ISAPPROVAL: <br /> SBD-6398(R.11/97) DISTRIBUTION: Original to County,One copy To: Safety&Buildings Division,Owner,Plumber <br />