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Safety and Buildings <br /> SANITARY PERMIT APPLICATION 201 W.Washington Avenue <br /> N I tonin P 0 Box 7302 <br /> Department 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 County <br /> than 8 1/2 x 11 inches in size. Q <br /> • See reverse side for instructions for completing this application state S3nitai P3rmi u({m�blJer� <br /> Personal information you provide may be used for secondary purposes ❑Cneck it revision to©ious apviication <br /> (Privacy Law,s. 15.04(1)(m)]. State Plan I.D.Number <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INFO RMATION I lr 'r <br /> Prope Owner me Property Location loph <br /> 6M 1,M5\1 1/4 1/4,S 34 T N,R 1(0 E(or <br /> Prope yOwnei's Mailin- Address Lot Number Block Number <br /> C ty,State W Zip Code Ph n��uuumber SubdirvZion Name or CSM Number <br /> it 111 . 401 (tri ) 4b-WS3 I �_ Z I i G-�ov - a" <br /> II. TYPE OF BUILDING: (check one) E] State Owned ❑ uty Nearest Road <br /> illa <br /> Public 1 or 2 FamilyDwelling-No.of bedrooms TVowng10 F OF1QD- <br /> III. BUILDING USE: (If building type is public,check all that apply) Parcel TaxNumber(s) <br /> 1 ❑ Apartment/Condo 02.0 4334 Ca. Zicko <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 Q 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.,V Replacement 3. [:] Replacement of 4. ❑ Reconnection of 5. E] Repair of an <br /> S stem __ System Tank Only ______ Existing System _______ Existing System <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 {Seepage Bed 21 ❑Mound 30❑Specify Type 41 ❑Holding Tank <br /> 12 b Seepage Trench 22 Q 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. F <br /> 4o inal Grade <br /> SRequired(sq.ft.) Pro osed(sq.ft.) (Gals/day/sq.ft.) (Min./inch) Elevation <br /> G�4 00 � q I,9 Feet o*-2—Feet <br /> VII. TANK Capacity Site <br /> INFORMATION in gallons °tons Tanks Manufacturer's Name co�c ere Con- Steel yless Plastic APpr. <br /> New Existin strutted <br /> Tanks Tanks <br /> Septic Tank or Holding Tank ❑ ❑ ❑ 11 <br /> 01 <br /> Lift Pump Tank/Siphon Chamber El IEl 0 El <br /> 11 <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(No Ilyl mps) MP/MPRSW No.: Business Phone Number: <br /> cA.R12D 4opkidS `74- 8106- 571 <br /> PI mber's Address(Street,City,State,Zip Code'):I/ <br /> 7.1"1&0 tv WE I. <br /> IX. COUNTY/DEPARTMENT USE ONLY10 <br /> ❑Disapproved S nitaryPermitFee (ISurchar Surcharge <br /> ate issuedIssuin entSi tur ( ps) <br /> surcharge Fee) <br /> pproved QOwnerGiven Initial -�f t� V-;*001 <br /> Adverse Determination / ✓ <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SBD-6396(R.4/99) DISTRIBUTION: Original to County.One copy To: Safety a Buildings Division.Owner,Plumber -- <br />