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Safety and Buildings Division <br /> Visconsin SANITARY PERMIT APPLICATION 201 W.Washington Avenue <br /> 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 J <br /> than 8 112 x 11 inches in size. �36 <br /> • See reverse side for instructions for completing this application State Sanitary Permit N/uumbber Jll <br /> Personal information you provide may be used for secondary purposes ❑check'vislontoprevious application <br /> (Privacy Law,s. 15.04(1)(m)]. State Plan I.D.Numbest <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INF RMATION I <br /> Property 02.nper Name Property Location <br /> 3uQ FU 114 1/4,S 3 T N,R 14 E(or(q) <br /> Property Ownersailing Address Lot Number re i <br /> City,State Zip Code P cl e N tuber Subdivi ion Name or CSM Num er <br /> nJ . ( �1 ) 1- ob �yjjicahm "Ib <br /> II. TYPE OF ING: (check one) ❑ State Owned ❑ Its Nearest Road Ad'pL dr <br /> Village '^ <br /> Public 1 or 2 FamilyDwelling-No.of bedrooms Town OF S(i0�' <br /> III. BUILDING USE: (If building type is public,check all that apply) Parcel TaxNumber(s) <br /> 1 ❑ Apartment/Condo I 2$ glgO 02 200 <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. 1 <br /> 9 <br /> New 2. E] Replacement 3. [:] Replacement of 4. E] Reconnectionof -_ 5. E] Repair of an <br /> System __ ___ _ __ ___System Tank Only _ Existing System __ ExiSystem <br /> --- ----- <br /> ------ <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 05eepage 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 'l0 Q' ei- ,C. <br /> VI. ABSORPTION SYSTEM INFORMATION: -X6 IQ71 <br /> 1. Gallons Per Day 2. Absorp.Area 3. Absorp.Area 4. Loading Rate 5.Perc. Rate 6. System Elev. 17. Final Grade <br /> Required(sq.ft.) Proposed(sq.ft.) (Gals/day/sq.ft.) (Min./inch) Elevation <br /> 9,601-3 Feet %.g Feet <br /> VII. TANK Capacity Site <br /> INFORMATION in gallons Gallons Tanks Manufacturer's Name Concrete con- Steel glass Fiber- Plastic APp. <br /> New Existin strutted <br /> Tank` Tanks / <br /> Septic Tank or Holding Tank �rir� "T ( M/ E] El El El <br /> Lift Pump Tank/Siphon Chamber ❑ L E 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 tamps) MP/MPRSW No.: Business Phone Number: <br /> 1c14A" Ql�►�S �- ) �I - - <br /> Plumber'sAddress(Street,City State,Zip Code): <br /> Z?7&o (. S <br /> IX. COUNTY/ DEPARTMENT USE ONLY <br /> ❑Disapprove' <br /> SanitaryPermit F e (Includesrroundwater ate ssue Issuing Agent gnatur (No ps) <br /> Surcharge Fee) <br /> Approved E]Owner Given Initial y/ <br /> Adverse Determinationi / <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> oZL(Q� 'P�1- be,�vom ��UY�d 4h .5ee�aye ded��o,/��s�s�i/ �> Z�/y /1114/ <br /> SBD-6398(R.11197) DISTRIBUTION: Original to County.One copy To: Safety a Buildings Division,Owner,Plumber <br />