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Safety and Buildings Division <br /> ��� ��� Bureau of Building Water S <br /> r,.o•a.nn SANITARY PERMIT APPLICATION 201 E Washington Systems <br /> y eOs, <br /> In accord with ILHR 83.05,Wis Adm.Code P.O.Box 7969 N <br /> Madison,WI 53707-7969 <br /> • Attach complete plans(to the county copy only)for the system,on paper not less County <br /> than 8 12 x 11 inches in size. * i_b <br /> • See reverse side for instructions for completing this application State Sanitary Perr it Numer <br /> The information you provide may be used by other government agency programs ❑check it revision to previous application <br /> 73 <br /> [Privacy Law,s- 15.04(1)(m)l. <br /> State Plan I.D.Number <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION /q�/ <br /> Property Owner Name Property Location <br /> nn,,►'►irIS O trsrn n� <br /> Com ►'1e.► -1/4,5 1,S T 39 N, R 14 f*w)W <br /> Property Owner's Mailing Address LOrWarITer .Pe I O Block Number <br /> A 42q l2h �£ ok7N <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> c,S M I 5Gq 06" (4UL)37q_3783 <br /> II. TYPE F BUILDING: (check one) ❑ State Owned E) ity Nearest Road <br /> Public 1 or 2 FamilyDwelling- No.of bedrooms Z_ VII( <br /> OF lage Z&5✓. i�sN�pK. S <br /> III. BUILDING USE: (If building type is public,check all that apply) Parcel Tax NuLmbber(s) <br /> 1 ❑ Apartment/Condo Q� / — 3115- Q/ <br /> If 6 <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- o New 2. ❑ Replacement 3. ❑ Replacement of 4- ❑ Reconnection of 5_ ❑ 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>gSeepage 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 /> Requir d(sq. ft.) Prop,oQsed(sq.ft.) (Gals/day/sq. ft.) (Min./inch) Elevation <br /> 3Qo 732 . -2 n'!or lr 15L21 b Feet 94.3 Feet <br /> VII. TANK Capacity <br /> INFORMATION in gallons Total #of Manufacturer's Name Prefab. Site Fiber- Exper. <br /> Gallons Tanks Concrete Con- Steel lass Plastic Ap <br /> New Existin structed 9 App <br /> Tanks Tanks <br /> Septic Tank or,HoldmijTan1. pOb DO � ® ❑ ❑ ❑ ❑ ❑ <br /> I Ift Pump Tank/Siphon Chamber ❑ ❑ ❑ ❑ ❑ ❑ <br /> VIII. RESPONSIBILITY STATEMENT <br /> I, the undersign me respor6ibility for insta tion of the onsite sewage system shown on the attached plans- <br /> Plum ber's <br /> lans.Plumber's ll�pt& EXCAVATIO a "s Signat :(No Stamps) Te/MPRSW No.: Business Phone Number: <br /> NB228 Colum Lin•Rd. <br /> Plumber's Addres p Code): <br /> (715)835-7482 <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑Disapproved Sanitary Permit Fee (includes Groundwater ate Issue Issuing Ag t gnat e S ps) <br /> roved ha e f eel <br /> p ❑Owner Given Initial / X �� <br /> Adverse Determination l U <br /> X. CONDITIONS OF APPROVAL/REASONS FOR SAPPROVAL: <br /> SBD-6396(B,05/94) DISTRIBUTION: Original to County,One<oPy To: Safety y Buildings Divcwn,Owner,Plumber <br />