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&P (f Safety and o.... <br /> SANITARY PERMIT APPLICATION 201 W.Washington Avenue <br /> N%As6onsiD In accord with Comm 6305Wis.AdmCode <br /> om . , . . P O Box 7302 <br /> Departmentpf Commerce 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. <br /> • See reverse side for instructions for completing this application State Sanitar PermmtNNumb(eJr <br /> Personal information you provide may be used for secondary purposes E]Check ifsion lO <br /> prev ap8 cion <br /> lPrivacy Law,s. 15.04(1)(m)]. State Plan I.D.Number <br /> I. APPLICATION INFORMATION- PLEASE PRINT ALL INF RMATI N ✓ l/ <br /> PropjwyOwnerName Property Location <br /> NAAB 1/4 1/4,S 1 T 401N, R 14-E(or <br /> Property Owner's Mail inAddress Lot Num Block Number <br /> Cit State Zip Code Phone Numberubdiv ion Name or CSM Number <br /> 4 ( q.v. <br /> II. PE BUILDING: (check one) ❑ State Owned I ity Nearest Road Vif age Public 1 or 2 Famil Dwellin -No.of bedrooms :tEo <br /> Town OF <br /> III. BUILDING USE: (If buildingtypeispublic,check allthatapply) Parcel TaxNupOmber(s) <br /> 1 ❑ Apartment/Condo D�0—q 3cc)a--Q�_gOD <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. loll New 2. ❑ Replacement 1 ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an <br /> __System System _ Tank Only .............Existing System _ ___ ExistfngSystem <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,oSeepage Bed 21 ❑Mound 30❑Specify Type 41 E]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 15. Perc. Rate 6. System Elev. 1 7. Final Grade <br /> Required(sq.ft.) Proposed(sq.ft.) (Gals/da /sq.ft.) (Min./inch) 113.4 <br /> EI vation <br /> 45b 0---- Feet �.l Feet <br /> Ca aclt <br /> VII. TANK in gallons Total #of Manufacturer's Name Prefab. Con- Steel Fiber- Plastic Exper. <br /> INFORMATION New Existin Gallons Tanks concrete strutted glass App. <br /> Tanks Tanks <br /> Septic Tank or Holding Tank JX ❑ Il El 11 <br /> Lift Pump Tank/Siphon Chamber E] n ❑ o <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 Signatur :(N tamps) MP/MPRSW No.: Business Phone Number:5 <br /> PI mber's Address(Street,City, te,Zip Code). <br /> IX. COUNTY/ DEP AR�TUSENLY <br /> ❑Disapproved Sani ry Permit Fee (Includes Groundwater F77:1 <br /> Issuing Age t Signature( S mps) <br /> roved Sur Age ree) /J <br /> pp ❑Owner Given Initial � � C7� <br /> Adverse Determination <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 />