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Safety nd Buildings Division <br /> Visconsin SANITARY PERMIT APPLICATION 201 W.Washington Avenue <br /> P O Box 7302 <br /> In accord with ILHR 83.05,Wis.Adm.Code <br /> Department 2f Commerce Madison,WI 53 07-7302 <br /> • Attach complete plans(to the county copy only)for the system,on paper not less County � , nn <br /> than 8 1/2 x 11 inches in size. / <br /> • See reverse side for instructions for completing this application S e Sanitary Permit Number <br /> Personal information you provide may be used for secondary 3x-533 <br /> Y p Y ry purposes ❑Check it revision to prewou apptica4on <br /> [Privacy Law,s. 15.04(1)(m)]. <br /> State Plan I.D.Number <br /> I. APPLICATI N INFORMATION - PLEASE PRINT ALL INF RMATION <br /> Property Owner Name Property Location <br /> 911 1/4 1/4,S ZI T N, R E(or W <br /> Propert Owner's Mailing Address Lot Numberr <br /> IDW9Q pitijewr .L. ! <br /> City,State I Zi Code Phone Number Subdivision Name or CSM Number <br /> 4 (to t2 c <br /> 11. TYPE OF BU1LDING: (check one) ❑ State Owned ❑ itVily Nearest Road <br /> Public 1 or 2 Famil Dwellin -No.of bedrooms �— ❑ Town OFOA&A40 3s- <br /> III. BUILDING USE: (If building type is public,check all that apply) Parcel TaxNumber(s) <br /> 1 ❑ Apartment/Condo = f3Zj r)-Z- <br /> 2 <br /> )- — <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.X Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an <br /> ---Syrstem --------System -- Tank Only System Existin System <br /> stem <br /> ----------- - ---- <br /> -------------- <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 C95eepage 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 S.Perc. Rate 6. System Elev. 7. Final Grade <br /> 3o O Required(sq.ft.) Proposed(sq.ft.) (Gals/day/sq.ft.) (Min./inch) Elevation <br /> Z �� . 3 Feet Feet <br /> VII. TANKCapacit <br /> y <br /> INFORMATION in gallons Total #of Manufacturer's Name Prefab. Con Fiber- Plastic Ext <br /> New Existin Gallons Tanks Concrete Steel glass <br /> Tanks Tanks I <br /> structed <br /> Septic Tank or Holding Tank p #1-i <br /> W 11 El El El <br /> Lift Pump Tank/Siphon Chamber I ❑ El ❑ C <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: 05 ps) MP/MPRSWNo-: Business Phone Number: <br /> P umber's Address(Street,Cit tate,Zip Code). <br /> 7 W 1n� W). 5413 <br /> IX. COUNTY/ DEPARTMENT USE ONLY <br /> ❑Disapproved Sanitary Permit Fee (includes Groundwater ate IssuedIssuing ent Signature(No Stamps) <br /> Approved ❑Owner Given Initial / s"rchargeree) <br /> Adverse Determination (��' f� (� <br /> ONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398 IRA 1/97) DISTRIBUTION: Original to County,One copy To: Safety&Buildings Division,Owner,Plumber <br />