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Saf�Buildings Division <br /> SANITARY PERMIT APPLICATION m W.Washington Avenue <br /> onsin P O Box 7302 <br /> In accord with[LHR 83.05,Wis.Adm.Code Madison,WI 53707-7302 <br /> Commerce <br /> _�rrcamplete plans(to the county copy on <br /> for the system,on paper not less county <br /> than 8 1/2 x 11 inches in size. State Sanitary Permit Number <br /> • See reverse side for instructions for completing this application a�333 <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)]. State Plan I.D.Number <br /> I. APPLICATION INF RMATION- PLEASE PRINT ALL INF RMATION <br /> Propert Owner Name LJQ Property Location +� <br /> a tJ _4 1)4 114,5 ZS T ,NrR 4 E(or <br /> Prope y Owner's Mailing Address N Lot umi <br /> ID � o, 1>J � 6 <br /> City,Sta e 1 • ' Zi Crode Phone Number Subdivision Name or CSM Number <br /> �-� l� +`r MN- �j43 (��)a S-I <br /> y�OL• JiN�ear�es;tRoadP F IL IN : (check one) ❑ State OwnedvillagePublic 1or2Famil Dwellin -No.ofbedrooms Town OF !G�-fltJfl .$ bf�t�sorl 1.1�C.R0. <br /> III. BUILDING USE: (If building type is public,checkallthat apply) rcelTaxNumber(s) <br /> � ¢323 b? 700 <br /> 1 ❑ Apartment/Condo <br /> 2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Outdoor Recr al 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/Mote[ 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 1 ❑ Replacement of 4_ ❑ Reconnection of 5. ❑ Repair of an <br /> Tank OnlyExistin System _ _ Exlstina System <br /> _ 5 stem 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 /> 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 /> Req 'red(sq.ft.) Proposed(sq.ft.) (Gals/day/sq.ft.) (Min./inch) Elevation <br /> 46D4P 172F-� Feet (�-6 Feet <br /> VII. TANK Ca cit 1 900 , <br /> in gallons Total #of Manufacturer's Name Prefab. Site <br /> Steel Fiber- Plastic Exper. <br /> INFORMATION New Existin Gallons Tanks Concrete structed glass app. <br /> Tanks Tanks O ❑ ❑ 0 <br /> Septic Tank or Holding Tank e 1� 1 ❑ ❑ El ❑ <br /> ry <br /> Lift Pump Tank/Siphon Chamber faw j% <br /> 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:( o St ps) MP/MPRSW No.: Business Phone Number: <br /> Pilimber's Address(Street,City,State, Cod jCQ� <br /> '2-'714)0 1 Ga.�r�r� 1N <br /> IX. COUNTY/ DEPARTMENT USE ONLY <br /> Disd roved Sanitary Permit Fee tin°udesGroundwater ate Issue Issuing gent Signature(No Stamps) <br /> ❑ pp Surcharge Fee) P <br /> -*P <br /> proved ❑Owner Givenlnitial <br /> Adverse Determination <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> DISTRIBUTION: Original to County.One copy To: Safety B Buildings Division,owner,Plumber <br /> SBD-6398(R.11197) <br />