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-� .� Safety and Buildings Division <br /> SANITARY IT APPLICATION 201 E.Washington Ave. <br /> `�SCOnSin In accord with ILHR 83.05,Wis.Adm.Code P.O.Box <br /> Department of L<Ommerce Madison,WI WI 53707.7969 <br /> 9 .Attach complete plans(to the county copy only)for the system,on paper not less County �1 1Cf(/� <br /> than 8 112 x 11 inches in size. ���/�e as ' "' <br /> • See reverse side for instructions for completing this application State San it Pe it Numbeer Q <br /> t/QYThe information you provide may be used by other government agency programs ❑Check it i sio o prevI us pplication <br /> [Privacy law,s. 15.04(1)(m)]. State Plan I.D.Number <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INF RMATION 1 0 <br /> Prope Owner Name Property Location <br /> o e r Z e SC t T6 ,N, R/SE(or� <br /> Property ner's Mailing Addresst Number Block Number <br /> g G e e F lfd NG 1_' <br /> City,State Zip Code Phone Number vision Name or CS 'jber <br /> e45Aer' �✓F rY293 ( )X9 2V3 <br /> TYPE OF BUILDING: (check one) ❑ State Owned ❑ uty Nearest Road <br /> ❑ Village 7�C� S o�j L <br /> Public 1 or 2 FamilyDwelling-No.of bedrooms Town of V <br /> III. BUILDING USE: (If building type is public,check all that apply) Parcel Tax Number(s) <br /> 1 ❑ Apartment/Condo <3 1.2 <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. ❑ New 2. Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5- ❑ Repair of an <br /> System System _ ______ __ Tank-Only- ___________ Existing System _______ExistingSystem <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 5(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-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) j (/ Elevation <br /> Y15-0 6 �9/� e l "— !`�' < Feet / S Feet <br /> VII. TANK Capacity Site <br /> INFORMATION in gallons Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic APPr <br /> New Existin strutted <br /> Tanks Tanks �( <br /> Septic Tank or Holding Tank ODO /aDD S�-�4w C? ❑ ❑ ❑ 1 ❑ <br /> Lift Pump Tank/Siphon Chamber ❑ 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's Signature:(No Stamps) MP/MPRSW No: Business Phone Number: <br /> L✓.4r.�c., /Pv�s�'ol�, l�t/d� ���69 -�Yi-��6 <br /> Plumber's Ar dress(Street,City,State,Zip Code): <br /> IX. COUNTY/DEPARTMENT USE ONLY +' <br /> ❑Disapproved Sanitary Permit Fee (includes Groundwater ate ue Issuing Agent Signature(No S mps) <br /> roved ��� urchargeFee) / <br /> lk—pp ❑Owner Given Initial a7 (� <br /> Adverse Determination <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> sBD-6398(R.11196) DISTRIBUTION: Original to County.One copy To: Safety 8 Buildings Division.Owner,Plumber <br />