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V <br /> Safety and Buildings Division <br /> ����,, enue <br /> SANITARY PE^MIT APPLICATION 201 W.Washington 0 Bo 7162 <br /> NOsconsin P o 707 7162 <br /> Department of Commerce <br /> In accord with Comm 83.05,Wis.Adm.Code Madison,WI 53707-7162 <br /> • Attach complete plan5(to the county copy only)for the system,on paper not less [Countyf)9cthan 8 12 x 11 inches in size. <br /> • -See reverse side for instructions for completing this application e Sanitary�Perrmit Nu;Nbe <br /> Personal information you provide may be used for secondary purposes heckavl d?Eo6rrevation[Privacy Law,s. 15.04(1)(m)]. e Plan Review Transactir <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INF RMATION - <br /> Property Owner NX, Property Q <br /> CLC/ U 1�.� /Ulf/4 Lc ij/4, .�z T �N� E(or�NProperty Owneis Mailing Addres r Lot Number Block Num <br /> Sov A C.e9e//sere S <br /> Ciitty,,State �S r ZI4 Phone Number Subdivision Name or CSM Number <br /> 3W Vo <br /> IL G: (check one) ❑ State Owned 71 Lit ffNeast RoadIr.7YPE OF ❑Lit �a rKS /1 <br /> Public F1 1 or 2 Family Dwelling-No.of bedrooms Town OF <br /> III. BUILDING USE: (If building type is public,check all that apply) Parcel TaxNumber(s) <br /> 1 ❑ Apartment/Condo Q ele -- -Z Z —d Z — 40 0 <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 FOChurch/School 8 ❑ 12 Mobile Home Park ❑ Service Station/Car Wash <br /> 5 ElHotel/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. 193 Replacement 3_ ❑ Replacement of 4. ❑ Reconnection of 5_ ❑ Repair of an <br /> System System _ Tank Only Existing System _-_______E ---2cSystem <br /> B) ❑ ASanitary 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 /> Required(sq.ft.) Proposed(sq.ft.) (Gals/day/sq.ft.) (Min./finch) Ele nation <br /> 1 O _ Feet Feet <br /> VII. TANK <br /> Capacity <br /> in gallons Total #of Manufacturer's Name Prefab. con steel Fiber- plastic Exper <br /> INFORMATION New Existing. Gallons Tanks concrete strutted glass Apo <br /> - <br /> INFORMATION <br /> Tanks r <br /> Septic Tank or Holding Tank <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 /> Plum s Name:(Print) FuPlumbeLgignatu :( amps) MP/MPRSW No.: Business Phone Number: <br /> o er �cc lsen 6.s� --'are <br /> Plumber's Address(Street,City 5tate,Zip Ocie): <br /> Z / ,� � <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑Disapproved Sanitary Permit Fee Ilncludes eFee)water ate IssuedIssuing ent5ignature•(NoStamps) <br /> Pfr /�� surcharge reel <br /> Approved []Owner Given Initial mCLLf� <br /> Adverse Determination <br /> CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(RA 2199) DISTRIBUTION: Original to County.One copy To: Safety 8 Buildings Division,Owner,Plumber <br />