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Safety and Buildings Division <br /> Visconsin SANITARY PERMIT APPLICATION 201 W.Washington Avenue <br /> P O 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 81/2 x 11 inches in size. U f1^nJ Q <br /> • See reverse side for instructions for completing this application state sanitarrPPer�mit N-u�mbbjer �J <br /> Personal information you provide may be used for secondary purposes ❑Check itrevlslon to previouTa lication <br /> [Privacy Law,s. 15.04(1)(m)]. State Plan I.D.Number <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INF RMATION 1 Ala o-?5/ <br /> Propert Owner NameProperty Location <br /> a �r G�o0C / SE1/4 s4 1/4,S S T�g ,N, R1B E(or)VV <br /> Propert ner's Mailing Pddre Lot Number Block Number <br /> 27q <br /> City,Stgg Zip Code Phone Number Subdivision Name or CSM Number <br /> Ill. TYPE OF BUILDING: (check one) ❑ State Owned It� / p 1 Nearest /adVle <br /> o <br /> Public 1 or 2 FamilyDwelling-No.of bedrooms jZ jZ Town OF Ooo! �(/v e�` L� i Lk tfol, <br /> III. BUILDING USE: (if building type is public,check all that apply) Parcel Tax Number(s) <br /> 1 ❑ Apartment/Condo ©41;2 3 6 �7d0 <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. New 2. [:] Replacement 3. [j Replacementof 4. E] Reconnection of 5. ❑ Repair of an <br /> ---__-ystem ________System ------------- Tank Only_____---_---_- Existing System _________Existi^-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 /> 11 ❑Seepage Bed 21 ❑Mound 30❑Specify Type 41 WHolding 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. 17. Final Grade <br /> Required(sq.ft.) Proposed(sq.ft.) (Gals/day/sq.ft.) (Min./inch) Elevation <br /> � 6 Feet Feet <br /> Ca acit <br /> VII. INFORMATION in gallons Total #of Manufacturer's Name Prefab. Site Con- steel Fiber- Plastic Exper. <br /> New Existin Gallons Tanks Concrete structed glass App. <br /> Tanks Tank �yI <br /> Septic Tank or Holding Tank a2ch0 �� A__J, ❑ ❑ ❑ ❑ ❑ <br /> Lift Pump Tank/Siphon Chamber I ❑ ❑ ❑ ❑ ❑ ❑ <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) Plumber's Signature:(No Stamps) MP/MPRSW No.: Business Phone Number: <br /> Z4_)14 Oil <br /> Plumb is Address(Street,City,State,Zip Code): <br /> 7O7 '5-1se- /`tt-./ <br /> IX. COUNTY/DEPARTMENT USE ONLY <br /> ❑Disapproved Sanitary Permit Fee (Includes Groundwater Date Issued Issuing Agent Signature(No Stamps) <br /> A roved Surcharge Fee) <br /> ,4 <br /> pp ❑Owner Deter <br /> rnii al /qs 0>6) <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 />