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ASafety�fSd 6�31dingr " sdivision <br /> sOonsin SANITARY PERMIT APPLICATION 201 W.Washington Avenue <br /> Department of Commerce In accord with Comm 83.05,Wis.Adm.Code P O Box 7302 <br /> Madison,WI 53707-7302 Q <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. + <br /> • See reverse side for instructions for completing this application St to Sanitary Perm it Numbepr <br /> Personal information you provide may be used for seconds purposes "" � R ! <br /> secondary p E]Check if to to previous application <br /> [Privacy Law,s. 15.04(1)(m)]. <br /> State Plan I.D.Numb rrr <br /> I. APPLICATION INFORMATION - PLEASE PRINT ALL INF RMATI N b t <br /> ProPejjv Owner Name Property Location <br /> 1W ffi62� 1/4 1/4,S 23 T q0 ,N, R 1'7 E(or) <br /> Prop tyowne sMailingAddress Lot Number gleek-yav"yef <br /> ity,State Zip Code P neNumber Subdivision Name or CSM Number <br /> ►� � ( S p 124 <br /> 11. P LDING: (check one) ❑ State Ownedity Nearest Road <br /> Public 1 or 2 Famil welling-No.of bedrooms � � Vown <br /> - II ageOF NION Al ,DA- <br /> III. BUILDING USE: (If building type is public,check all that apply) Parcel TaxNumber(s) <br /> 1 ElApartment/Condo I036 423 OS 403 <br /> 2 ❑ Assembly Hal[ 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.�d New 2. E] Replacement 3. E] Replacement of 4_ E] Reconnection of 5_ F] Repair of an <br /> ------System----------System -____ _-_ _ Tank-Only--------- _-_ Existing System -_ 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 /> 11 ❑Seepage Bed 211KMound 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 /> 2. Absorp.Area 3. Absorp.Area 4. Loading Rate 5. Perc. Rate 6. System Elev. 7. Final Grade <br /> Re wired(sq.ft.) Prop ed(sq.ft.) (Gals/da /sq.ft.) (Min./inch) Elevation <br /> 300 iqso �i0 — 7, 9 Feet1010-Z Feet <br /> 1. Gallons Per Day <br /> VII. TANK Capacity <br /> INFORMATION in gallons Total #of Manufacturer's Name Prefab. doe Fiber- plastic Exper. <br /> New Existin Gallons Tanks Concrete Steel glass App. <br /> structed <br /> Tanks Tanks <br /> Septic Tank or Holding Tank <br /> Lift Pump Tank/Siphon Chamber 1—H E1 Q Q ❑ ❑ <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 Signatur �(N mps) MP/MPRSW No.: Business Phone Number: <br /> Plumber's Address(Street, ity,State,Zip Code) <br /> 2 o ss' csrra III 0i. 54993 <br /> IX. COUNTY/DEPA MENT USE ONLY <br /> ❑Disapproved Sanitar P rmitFee (Includes Groundwater ate Issued Issuing g t5ign ?urr ps) <br /> roved O rrh�geFFe) �� <br /> pP ❑Owner Given Initial 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&Buildings Division,Owner,Plumber <br />