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L) � " " r Safety and Buildings Division <br /> SANITARY PERMIT APPLICATION 201 W.Washington Avenue <br /> Visconan. In accord with ILHR 83.05,Wis.Adm.Code P O Box 7302 <br /> Departmer.4 of Commerce Madison,WI 53707-7302 <br /> • Attach complete plans(to the county copy only)for the system,on paper not less County a ar L <br /> than 8 1/2 x 11 inches in size. lJ� <br /> • See reverse side for instructions for completing this application StateSanitary Permit N tuber <br /> Personal information you provide may be used for secondary purposes ❑check it revision to pr ious application <br /> (Privacy Law,s. 15.04(1)(m)). State Plan I.D.Number <br /> 1. APPLICATION INFORMATION - PLEASE PRINT ALL INF RMATION <br /> Property Owner Name Property Location <br /> ERN5117 1/4 1/4,S I T 40 ,N,R 14- E(or VGy <br /> Propert O ner's Mailing Address Lot Number Block Number <br /> City,State I Zip Code Phone Number Subdivision ameorCSMNu ber <br /> 11. <br /> trill <br /> T P IL IN : (check one) ❑ State Owned ❑ It� rN=rest Road <br /> Public 1 or 2 Famil Dwellin -No.of bedrooms Z N town of AsJ5COM 1X-TR-WAt <br /> 111. BUILDING USE: (If building type is public,check all that apply) Parcel TaxNumber(s) <br /> 1 ❑ Apartment/Condo VZ% 9376 05 900 <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. ]g New 2. ❑ Replacement 3_ ❑ Replacement of 4_ ❑ Reconnection of 5_ ❑ Repair of an <br /> System System ____ ______ Tank Only---------------Existing System ___ ____ExistIf2q yystem <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 /> 11Seepage Bed 21 E]Mound 30 E]Specify Type 41 E]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) Q Elevation <br /> 2� 32 ,7 qb•S Feet 19.0 Feet <br /> TANK Capaat <br /> VII. INFORMATION in gallons Total #of Manufacturer's Name Prefab. Co'itn- Steel Fiber- Plastic Exper. <br /> New Existin Gallons Tanks concrete strutted glass App. <br /> Tanksl Tanks <br /> Septic Tank or Holding Tank SKiil ® 1 ❑ ❑ ❑ ❑ ❑ <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:(No mps) MP/MPRSW No.: Business Phone Number: <br /> &f4RRo 14oegv4s I Z,Z.,5*51 S' Bbl.- 457 <br /> PI mber's Address(Street,City,State,Zip Code): <br /> 2_37&0 � Uj5o5tr(Z wt . <br /> IX./COUNTY/DEPARTMENT USE ONLY <br /> ❑Disapproved Sanitary Permit Fee (includes Groundwater Faq_ql� <br /> e IssuedIssuingly ent Signature(No Stamps) <br /> roved Surcharge Fee) <br /> pp ❑Owner Given Initial (RD, � <br /> Adverse Determination <br /> I 2k <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(R.11197) DISTRIBUTION: Original to county.One copy To: Safety&Buildings Division,Owner,Plumber <br />