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Safety and Buildings Division <br /> 14sconsin SANITARY PERMIT APPLICATION 201 E.Washington Ave. <br /> In accord with ILHR 83.05,Wis.Adm.Code P.O.Box 7969 <br /> Department of Commerce Madison,WI 53707-7969 <br /> • Attach complete plans(to the county copy only)for the system,on paper not less County Z �1 �7 <br /> than 8 112 x 11 inches in size. <br /> • See reverse side for instructions for completing this application StateSanitar rmiNuumbeerr <br /> The information you provide may be used by other government agency programs E]Check it revisiontd previv�application <br /> [Privacy Law,s. 15.04(1)(m)]. State Plan I.D.Number <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INF RMATION <br /> Propgrty Owner Name Property Location <br /> d//) u�o/ �� ��c 1/4IV� 1/4,S /� T�� ,N, R / E(or) <br /> Property Owner's Mailing Address Lot Number Block Number <br /> City,State l`LJc/1 Zip Code Phone Number Subdivision Name or CSM Number <br /> II. TYPE 0 BUILDING: (check one) ❑ State Owned city Nearest Road <br /> ❑ <br /> Villa <br /> / <br /> 171 Public 1 or 2 FamilyDwelling-No.of bedrooms .< Town OF ! __ 15 <br /> III. BUILDING USE: (If building type is public,check all that apply) Parcel Tax Number(s) <br /> 1 ❑ Apartment/Condo Oo&/ xn <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. KNew 2. ❑ Replacement 3. ❑ Replacementof 4_ ❑ Reconnection of 5_ ❑ Repair of an <br /> ------System --------System -_-__ __ __ Tank Only---------------Existing System - - ____ExistingSystem <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 E 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./inch) cy�/X� Elevation <br /> C�d a a i / Feet 72 3 Feet <br /> TANK Capact <br /> VII INFORMATION Site <br /> in allons Total #of Manufacturer's Name Prefab Con- Steel Fiber- Plastic Fxper <br /> New Existin Gallons Tanks Concrete structed glass App- <br /> Tanks Tanks <br /> Septic Tank or Holding Tank L}v t soe,¢e�) ❑ ❑ ❑ I ❑ ❑ <br /> Lift Pump Tank/Siphon Chamber ❑ ❑ ❑ ❑ ❑ ❑ <br /> Vlll. 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)n Plumber's Signature: No Stamps) MP/MPRSWNo.: BUSinessPhone Number: <br /> PIumbbber's Ac dress(Street,City,State,Zip Code): 77 <br /> IX. COUNTY/ DEPARTMENT USE ONLY <br /> Disapprove <br /> Sanitary p/ermitFee (Includes Groundwater F <br /> te issuedIssuin A ntSig a Stamps) <br /> V roved { �� � rcharge Fee) '���� <br /> 'v pp [-]Owner Given Initial / � <br /> Adverse Determination <br /> X. CONDITIONS OF APPROVAL/REASONS FORDISAPPROVAL: <br /> SBD-6398(R.11/96) DISTRIBUTION: Original to County.One copy To: Safety 8 Buildings Division,Owner,Plumber <br />