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Safety and Buildings Division <br /> SANITARY PERMIT APPLICATION 201 W.Washington Avenue <br /> VisCun.dn In accord with ILHR 83.05,Wis.Adm.Code P O Box 7302 <br /> Department of Commerce Madison,WI 53707-7302 <br /> • Attach cbmplete plans(to the county copy only)for the system,on paper not less County �z 3C07 <br /> than 81/2 x 11 inches in size. <br /> r <br /> • See reverse side for instructions for completing this application states nitary Permit Number U <br /> Personal information you provide may be used for secondary purposes ❑check INrevpfevlo'us application <br /> [Privacy Law,s. 15.04(1)(m)]. State Plan I.D.Number <br /> I. APPLICATION INFORMATION- PLEASE PRINT ALL INF RMATION <br /> ProperOwner Name Property Location 7-4 <br /> 1/4 1/4,S <br /> 36FE P16114 -110 ,N,R 14E(or <br /> Propert Owner's Mailing Address Lot Number Bleck D1-imbpr <br /> RlS&S 02 L. <br /> Cit tate =Code Phone Number Subdivi 'on Name or CSM Number <br /> ( !S 4%-Sim; Joy. / L V <br /> IL DI : (check one) ❑ State Owned EI LITY Nearest Road <br /> El Public 1 or 2 FamilyDwelling-No.of bedrooms _23— o gown of Sear � <br /> III. BUILDING USE: (if buildingtype is public,check all thatapply) Parcel TaxNumber(s) <br /> ba�- L40,4- c3- 3:" <br /> 1 ❑ Apartment/Condo <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. E] Replacement of 4. ❑ Reconnection of 5, ❑ Repair of an <br /> ------ ----------_ System -__ _ ___ __ Tank Onlystin <br /> - ____ ___ Exig5ystem __ _ _ 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 ❑Seepage Bed 21 ❑Mound .30❑Specify Type 4A <br /> olding Tank <br /> 12 E]Seepage Trench 22❑In-Ground Pressure it 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 /> 4SG Regi reeled(sq.ft.) Proposed(sq.ft.) (Gals/day) ft.) (Min./ir Elevation <br /> VII. TANK Capacity site <br /> in gallons Total #of Manufacturer's Name prefab Con- steel Fiber- Plastic New Existin Gallons Tanks Concrete strutted glass App. <br /> Tanks Tank <br /> Septic Tank or Holding Tank 7g50 ^ ?�Sfl ElEl 11 El 11 <br /> El El I El Q El El <br /> Lift Pump Tank/Siphon Chamber <br /> VIII. RESPONSIBILITY STATEMENT <br /> 1,the undersigned,assume responsibility for installation of the onsite sewage system shown on the attached plans. <br /> Plumber's Name:(Print) Plumber's Signature: o mps) MP/MPRSWNo.: Business Phone Number: <br /> 461 <br /> PI mbees Address(Street,Cl y,State,Zip Code): <br /> 2l1Go tl S tJ f- <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑Disapproved Sanitary Permit Fee Illnrwdeserovndwacer 7es Issuing gSigna re(No ps) <br /> A roved (�OurchargeFee)pp ❑OwnerGivenlnitial 7j�i/ � <br /> Adverse Determination <br /> X. CONDITIONS OF APPROVAL/REASONS FORDISAPPROVAL: <br /> .SBD-6398(8.11/97) DISTRIBUTIONOriginal to County.One copy To: safety B Buildings Division,Owner,Plumber <br />