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Safety and Bui�ivision <br /> *6onsin SANITARY PERMIT APPLICATION 2 1 B WashingtonAvenue <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 8112 x 11 inches in size. d� <br /> • See reverse side for instructions for completing this application St a Sanitary Permit Number <br /> 3(�oZ73� <br /> Personal information you provide may be used for secondary purposes E]Check if revision to previous application <br /> [Privacy Law,s. 15.04(1)(m)]. State Plara,4p./Vynber 5_ <br /> 1. APPLICATION INFORMATION - PLEASE PRINT ALL INF RMATION c../C 11// ((((J�J� 11//QQ_ <br /> Propert Owner Name Property Location <br /> 1/4 1/4,S T40 ,N, R `(p E(or <br /> Property Owner's Mailing Address Lot Number Block Number <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> ilsr. u I (Gsl > - z <br /> II. TYPE OF BUILDING: (check one) ❑ State Owned 0 it Nearest Road <br /> Public 1 or 2 FamilyDwelling-No.of bedrooms Z ElTowan OFONaMb CAWW Lk- my. <br /> III. BUILDING USE: (if buildingtype is public,check all thatapply) Parcel TaxNumber(s) <br /> 1 ❑ Apartment/Condo 20 <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 online B,if applicable) <br /> A) 1. ❑ New 2..M Replacement 3_ ❑ Replacement of 4. ❑ Reconnection of 5_ ❑ Repair of an <br /> ______System --------System ------------_ Tank-Only-------------- ExistinQSystem----------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 /> 12 El Seepage Trench 22 E]In-GroundPressure 42❑Pit Privy <br /> 13❑Seepage Pit 43❑Vault Privy <br /> 14❑System-In-Fill <br /> Vi. ABSORPTION SYSTEM INFORMATION: <br /> 2. Absorp.Area 3. Absorp.Area 4. Loading Rate 5. Perc. Rate 6. System Elev. 7. Final Grade <br /> Req ' ed(sq.ft.) Proposed(sq.ft.) (Gals/day/sq.ft.) (Min./inch) Elevation <br /> Feet Feet <br /> 1.Gallons Per Day <br /> TANK Capacit <br /> VII. INFORMATION Con- steel in allons Total #of Manufacturer's Name Prefab. Fiber- Exper. <br /> Gallons Tanks Concrete glass Plastic App <br /> New Existin strutted <br /> Tanks Tanjksl <br /> Septic Tank or Holding Tank E] ❑ El 1:1 1:1 <br /> -Ill I <br /> Lift Pump Tank/Siphon Chamber ❑ ❑ ❑ ❑ ❑ ❑ <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 (N mps) MP/MPRSW No.: Business Phone Number: <br /> cliA+2u OWWAIS =58P (S- 964- In <br /> P mber's Address(Street,City State,Zip Code): <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑Disapproved Sawar Permit Fee (In`IudesGroundwater ate Issued Issuing A Sign ur t mps) <br /> 4pproved ❑ _`fvl7S_�5urchargeree) <br /> v Owner Given Initial <br /> Adverse Determination I7 <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(R.4/99) DISTRIBUTION: Original to County,one copy To: Safety a Buildings Division,Owner,Plumber <br />