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Safety and Buildings Division <br /> N*scAnsin SANITARY PERMIT APPLICATION 201 E.Washington Ave. <br /> In accord with ILHR 83.05,Wis.Adm.Code P.O.Box 7969 <br /> Department of Commerce Madison,WI 53707.7969 <br /> r + <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. a.oZ <br /> • See reverse side for instructions for completing this application statesani rryt NZ[ <br /> The information you provide may be used by other government agency programs E]Check ew n tt previous aapplication <br /> [Privacy Law,s. 15.04(1)(m)]. <br /> State Plan I.D.Number <br /> 1. APPLICATION INFORMATION - PLEASE PRINT ALL INF RMATION <br /> ProyOwner Name Property L cation <br /> WO UG 1 12_5T N, R (b E(o W <br /> Property OwneS s Mailing Address Lot Number Big-6 111 <br /> Sr. mtJ155 C01446.47 Zo3 CAU PC14LL RD. 3 i • 2- <br /> City,State I Zip Code Phone Number Subdivision Name or CSM Number <br /> oriEPS( f W1 , - VoL, 2:6;>6- 7 <br /> 11. TYPE FBUILDING: (check one) ❑ Statel Owned ❑ City Nearest Road <br /> village 1 S$ N. (�A pEti/ UC 1¢P- <br /> Public 1 or 2 FamilyDwelling-No.of bedrooms 2 own OF <br /> III. BUILDING USE: (If building type is public,check all that apply) Parcel Tax Number(s) <br /> 1 E] Apartment/Condo 032" 5334 �� 4-60 <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_ bd New 2. E) Replacement 3. [:] Replacement of 4_ E] Reconnection of 5. E] 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 /> 11VSeepage Bed 21 ❑Mound 30❑Specify Type 41 ❑Holding Tank <br /> 1 ❑�❑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 /> Req fired(sq.ft.) Proposed(sq.ft.) (Gals/day/sq.ft.) (Min./in(h) Q E evatilon <br /> Zq 2 7 �-- 12-� Feet , r Feet <br /> Capacity <br /> VII. INFORMATION in gallons Total #of Manufacturer's Name Prefab. Con- steel Site Fiber- Plastic Exper. <br /> New Existin Gallons Tanks Concrete strutted glass App. <br /> Tanks Tanks <br /> Septic Tank or Holding Tank ❑ ❑ ❑ ❑ ❑ <br /> Lift Pump Tank/Siphon Chamber ❑ ❑ ❑ ❑ ❑ ❑ <br /> Vlll. RESPONSIBILITY STATEMENT <br /> I,the undersigned,assume responsibility for installation of the onsite sewage system shown on the attached plans- <br /> Pu tier's Name:(Pint) Plub ' Signat :( Stamps) MP/MPRSW No.: Business Phone Number: <br /> t S <br /> PI mber's Ac dress(StreCity,State,Zip <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑Disapproved Sanitary Permit Fee (includes Groundwater ate ssue Issuing t Signa re ps) <br /> �pproved ❑ sur �ree) a� <br /> Owner Given Initial r e <br /> Adverse Determination J <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(8.11/96) DISTRIBUTION: Original to County.One copy To: Safety 8 Buildings Division,Owner,Plumber <br />