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Safety Division <br /> SANITARY PERMIT APPLICATION 201 W.Washington Avenue <br /> ioonsin P o Box 7302 <br /> tment 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 Co my <br /> than 8112 x 11 inches in size. 637a)) <br /> • See reverse side for instructions for completing this application S ate Sanitary Pe rt N ber t <br /> Personal information you provide may be used for secondary purposes ❑Check i i onTobre6b s app station <br /> IPrivacy Law,s. 15.04(1)(m)]. State Plan I.D.Number <br /> I. APPLICATION INFORMATION- PLEASE PRINT ALL INFORMATION <br /> Property Owner Name Property Location <br /> DR& Mc CONS 1/4 1/4,S 334 T40 ,N,R 14• E(o <br /> Propert Owner's Mailing Address Lot Number <br /> Seo MORtr L.N. nl <br /> City,State Zip Code Phone Number Subdivi ion Name or CSM Num4er <br /> Tww _ ( > 1S <br /> II. P ILDI G: (check one) E] State Owned ❑ Ity Nearest Road <br /> ❑ village <br /> Public 1 or 2 Famil Dwellin -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 <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.XNew 2_ ❑ Replacement 3_ ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an <br /> ------System ---- __System _____________ Tank Only--------------- stir t tem----------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 /> 11Seepage Bed 21 E]Mound 30❑Specify Type 41 C]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) 9!;.& <br /> Elevation <br /> 45D 12� 2S �� 9 S-(p Feet 00.1 Feet <br /> Ca act <br /> VII. FORMATION in allons Galltons Tanks Concrete site gbass AppExpe. <br /> g manufacturer's Name Con- Steel Plastic <br /> New Existin strutted <br /> Tanks Tanks MM <br /> Septic Tank or Holding Tank 000 < IZAIEL ❑ ❑ ❑ ❑ <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: o mps) MP/MPRSWNo.: Business Phone Number: <br /> PI mber's Address(Street,Ci y,State,Zip Code). <br /> �Mtv0 E!3 1- 3 <br /> IX. COUNTY/DEPARTIMENT USE ONLY <br /> ❑Disapproved nits���yyyPermit Fee (Includes Groundwater ate IssuedIssuing Ag nt gnatur (N Stam <br /> roved %.ir� SurchargeFee) <br /> pp ❑Owner Given Initial / / <br /> Adverse Determinatio ` <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6398(R.4/99) DISTRIBUTION: Original to County,One copy To: Safety b Buildings Division,Owner,Plumber <br />