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.win Safety and Buildings Division <br /> scnnsin SANITARY PERMIT APPLICATION 22010 W.W�ZngtonAvenue <br /> Department of Commerce In accord with Comm 83.05,Wis.Adm.Code Madison,WI 53707-7302 <br /> • Attach complete plans(to the county copy only)for the system,on paper not less County �/ <br /> than 81/2 x 11 inches in size. 't 6 O `G/�3 <br /> • See reverse side for instructions for completing this application State Sanitary Permit Number <br /> OD O (p <br /> Personal information you provide may be used for secondary purposes ❑Check it revision to previous application <br /> (Privacy Law,s. 15.04(1)(m)). <br /> State Plan I.D.Number <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION <br /> Property Owner Name ' 1 Property Location <br /> CTef?.F ftu,cje. A.,,,..,„4 $c,U1/4,S /3 T 8 ,N,R 7 E(er)-W' <br /> Property Owner's Mailing Address Lot Number Block Number <br /> 31 o a.. Pa ~F y ,/a„w✓ A t 7 <br /> City,Statf Zip Code Phone <br /> Number S r CSM Number <br /> /" r4d <br /> bac". I.U. . 5 35‘..D- (e31 ) #09 yc 9 c <br /> II. TYPE OF BUILDING: (check one) ❑ State Owne ❑ it� Nearest Road / <br /> 4/ Vil ane �I r t tr ictrrf*G+ (P-A//e7❑ Public � 1 or 2 Family Dwelling-No.of bedroo s- ( own OF T <br /> III. BUILDING USE: (If building type is public,check all that a ply) Parcel Tax Number(s) <br /> a . — 06°7— (33— '5(050 - 0 <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. ew 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 ❑Seepage Bed 21 ❑Mound 30❑Specify Type 41 ❑Holding Tank <br /> 1 Seepage Trench 22❑In-Ground Pressure 42❑Pit Privy <br /> 1 ❑Seepage Pit / E" 43❑Vault Privy <br /> 14❑System-In-Fill s�( /,Zo .. ..,'f <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 /> O OU Required(sq.ft.) Proposed(sq.ft.) (Gals/day/sq.ft.) (Min./inch) q/ <br /> /7 g''.7 Ub S" Feet Eglef vaton <br /> h Feet <br /> Ca acit <br /> VII. TANK in gallons Total #of Prefab. Site Fiber- Plastic Exper. <br /> App. <br /> INFORMATION Gallons Tanks Manufacturer's Name Concrete Co" Steel glass <br /> New Existing structed <br /> Tanks Tanks <br /> Septic Tank or Holding Tank Aso /DSO / ."-le ael-4_ /g1 ❑ ❑ ❑ ❑ ❑ <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:(No Stamps) MP/MPRSW No.: Business Phone Number: <br /> met re w 4), � eirl1w/Z d — C v �'�_ I .2P-./4:-C- I C ' /') 3 <br /> Plumber's Address(Street,City,State,Zip Code): W��� �.or it, <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑Disapproved Sanitary i(DI Permit Fee (Includes Groundwater Da a Issued Issuii��ngg/yAggeen igna re(N to ps) <br /> Approved ❑Owner Given Initial Adverse Determination ! surcharge Fee) ��/ <br /> i`' o i—� <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br />